Wise Moves and Seated Exercise Class Information Name * Address Line 1 * Address Line 2 Postcode * Date of Birth * Telephone Number * Email Address Please select your preferred class location: * Monday, Seated Exercise class, Stapleford Community Pavillion, 1.30pm-2.15pmTuesday, Hope House Beeston, 12:30pm-1:30pmWednesday, Stapleford Community Pavilion, 10am-11amThursday, Greasley Sports and Community Centre, 11am-12pm Please tick if you have any of the below medical conditions: Asthma COPD Risk Factor(s) for Osteoporosis Diabetes Hypertension Muscular-Skeletal Problems Overweight Raised Cholesterol Depression / Anxiety Disability Cancer Mental Health Parkinsons Medical / Additional Information What GP Practice are you registered with? * Have you had a fall within the last 2 years? Yes No How confident can you walk over uneven pavement without losing your balance? * Not Confident Slightly Confident Confident How confident can you pick up something from the floor (without support) without losing your balance? * Not Confident Slightly Confident Confident How confident can you sit and stand in a chair (without using your arms) without losing your balance? * Not Confident Slightly Confident Confident Health Professional's Details Name of Health Professional * Address of Health Professional Line 1 * Address of Health Professional Line 2 Postcode of Health Professional * Phone Number of Health Professional * Email of Health Professional * This information will be used in accordance with our privacy notice. Please see our website for full details here If you are human, leave this field blank.