Health Questionnaire

Last Name
Have you been diagnosed with a heart condition / shortness of breath / dizziness when you undertake physical activity? If yes please give more information above.
Are you currently prescribed any medication? If yes, please tell us about this in the box above.
Are you pregnant?
Do you have epilepsy? If so describe type.
Do you have diabetes mellitus and need to take insulin?
Do you consider yourself to have a disability, would you like to tell us about this and whether you may need hep to access the beach and sea?
Do you know of any reason that may affect your ability to take part in physical activity?
Do you promise to smile for the rest of the day when you achieve your aim / make progress? 😊
Please tell us the name and number of someone we can contact in case of an emergency.
Please enter your postcode above - this and all other information will only be held for the purposes of contacting you about Swim The Wight CIC courses.