Address *

Post code *

How did you find out about ‘I Can’? *

Have you been referred to I Can by a current I Can Therapy Centre customer?
NoYes

Preparing to become more active

The following questions will help to ensure that you have a safe physical activity experience. If you are unsure about any questions, please answer yes.

1. Have you experienced ANY of the following (A to F) within the past six months?

A. A diagnosis of / treatment for heart disease or stroke, or pain/discomfort/pressure in your chest during activities of daily living or during physical activity?
NoYes
B. A diagnosis of / treatment for high blood pressure (BP), or a resting BP of 160/90 mmHg or higher?
NoYes
C. Dizziness or light-headedness during physical activity?
NoYes
D. Shortness of breath at rest?
NoYes
E. Loss of consciousness/fainting for any reason?
NoYes
F. Concussion?
NoYes
2. Do you currently have pain or swelling in any part of your body (such as from an injury, acute flare-up of arthritis, or back pain) that affects your ability to be physically active?
NoYes
3. Has a health care provider told you that you should avoid certain types of physical activity?
NoYes
4. Has a health care provider told you that you should modify certain types of physical activity?
NoYes
5. Do you have any other medical or physical condition (such as diabetes, cancer, osteoporosis, asthma, spinal cord injury) that may affect your ability to be physically active?
NoYes

About your health and ability

Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months (including any problems related to old age)?
NoYes, limited a littleYes, limited a lot

About your mobility

Who is your emergency contact?

Contact name *

Declaration

I confirm the information provided is correct to the best of my knowledge. I understand that if I require manual handling assistance, I will bring someone with me to help me. I understand that if I am unable to take in, retain and reuse information, I will bring someone with me to help me. I understand that I will need to complete an Assessment and Induction to ensure my safe and effective use of the service and equipment. I confirm my details can be passed on to a member of the I Can Therapy Centre team. I will immediately inform a member of the team if I experience pain or discomfort whilst exercising, other than that which I have mentioned. I understand that I will complete a review assessment every 6 months to ensure my continued safe and effective use of the I Can Therapy Centre service.

Address *

Post code *

How did you find out about ‘I Can’? *

Have you been referred to I Can by a current I Can Therapy Centre customer?
NoYes

Preparing to become more active

The following questions will help to ensure that you have a safe physical activity experience. If you are unsure about any questions, please answer yes.

1. Have you experienced ANY of the following (A to F) within the past six months?

A. A diagnosis of / treatment for heart disease or stroke, or pain/discomfort/pressure in your chest during activities of daily living or during physical activity?
NoYes
B. A diagnosis of / treatment for high blood pressure (BP), or a resting BP of 160/90 mmHg or higher?
NoYes
C. Dizziness or light-headedness during physical activity?
NoYes
D. Shortness of breath at rest?
NoYes
E. Loss of consciousness/fainting for any reason?
NoYes
F. Concussion?
NoYes
2. Do you currently have pain or swelling in any part of your body (such as from an injury, acute flare-up of arthritis, or back pain) that affects your ability to be physically active?
NoYes
3. Has a health care provider told you that you should avoid certain types of physical activity?
NoYes
4. Has a health care provider told you that you should modify certain types of physical activity?
NoYes
5. Do you have any other medical or physical condition (such as diabetes, cancer, osteoporosis, asthma, spinal cord injury) that may affect your ability to be physically active?
NoYes

About your health and ability

Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months (including any problems related to old age)?
NoYes, limited a littleYes, limited a lot

About your mobility

Who is your emergency contact?

Contact name *

Declaration

I confirm the information provided is correct to the best of my knowledge. I understand that if I require manual handling assistance, I will bring someone with me to help me. I understand that if I am unable to take in, retain and reuse information, I will bring someone with me to help me. I understand that I will need to complete an Assessment and Induction to ensure my safe and effective use of the service and equipment. I confirm my details can be passed on to a member of the I Can Therapy Centre team. I will immediately inform a member of the team if I experience pain or discomfort whilst exercising, other than that which I have mentioned. I understand that I will complete a review assessment every 6 months to ensure my continued safe and effective use of the I Can Therapy Centre service.