Date of Birth

Gender - Select - Male Female Other

Ethnicity - Select - White Mixed or Multiple Ethnic Groups Asian or Asian British Black, African, Caribbean or Black British Other Ethnic Group (e.g. Arab)

British Passport - Select - Yes No

1. Have you been diagnosed with a heart condition and/or been instructed to participate in medically supervised activity?
Yes    No 
2. Have you ever felt pain in your chest during physical activity?
Yes    No 
3. Have you ever experienced chest pains when not participating in physical activity?
Yes    No 
4. Have you suffered with palpitations?
Yes    No 
5. Have you suffered with dizziness or fainting?
Yes    No 
6. Have you been diagnosed with high blood pressure?
Yes    No 
7. Have you recently undergone surgery (within two months)?
Yes    No 
8. Do you have existing bone or joint problems?
Yes    No 
9. Do you experience shortness of breath?
Yes    No 
10. Do you have Asthma?
Yes    No 
11. Do you have Haemophilia?
Yes    No 
12. Do you have Epilepsy?
Yes    No 
13. Do you have Diabetes Mellitus?
Yes    No 
14. Do you take prescribed medication that may affect your ability to exercise?
Yes    No 
15. Are you pregnant or have you recently given birth (within the last six weeks)?
Yes    No 

If you have answered ‘Yes’ to any of the questions listed from 1 to 15, we may require you to obtain written consent form your doctor before agreeing to allow you to participate in Shuai Jiao. We suggest that you talk to your doctor before becoming more physically active. Please tell your doctor about this questionnaire and the questions to which you have answered ‘Yes’.

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16. Do you smoke regularly (20 tobacco products a week or more)?
Yes    No 

17. Do you drink alcohol regularly (21 units a week or more)?
Yes    No 

18. Do you have a cholesterol level that is greater than 4.0 mmol/l?
Yes    No 

19. Do you consider yourself to be overweight?
Yes    No 

20. Do you take anabolic steroids and/or performance enhancing drugs?
Yes    No 

21. Do you have AIDS or are you HIV Positive?
Yes    No 

22. Do you have Hepatitis or are you a carrier?
Yes    No 

If you proceed with participation in Shuai Jiao and during this period your health changes so that you would subsequently answer ‘Yes’ to any of the questions in this questionnaire it is your responsibility to inform us immediately as you may need to change or possibly suspend your training. If you feel unwell due to a temporary illness (e.g. influenza or COVID-19 symptoms) it is advisable to stop training and recover properly.

If you unsure of the answer to any of the 22 questions listed, you may wish to seek medical advice before completing this form to ensure that it is completed accurately. Failure to complete this form accurately may invalidate your application for membership of the BSJU and its associated insurance scheme.

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Infectious Disease Questions

23. Do you receive the Infulenza (Flu) annual vaccination?
Yes    No 

24. How many doses of the COVID-19 vaccinaion have you recieved?
0 1 2 3 or more

25. Are you willing to take required vaccinations to travel outside of the UK?
Yes    No 

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General Health

26. Do you have any other health concerns that you feel might be relevant?
27. How many hours of sleep do you get typically each night?
28. When was your last general health check-up or physical examination?

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