11, Richmond Road THE
London E8 3HY SHARP
EN D
Information Form
Please complete this form if you are new to Sharp End inShape activities.
We need to keep accurate records of the people who use our services for a number of
reasons. Most importantly, it helps us improve our services and meet the needs of older
people in Hackney. Membership of The Sharp End is open to people aged 50 and over
who live in Hackney or the City of London.
Please note that all information you give us is confidential. In no circumstances will personal
information be passed to anyone else.
If you are in any doubt about undertaking new exercise regime please consult your GP. If
you have any concerns about starting exercise or if any of the exercises cause you pain or
discomfort please do not do them and discuss this with your tutor at the end of the session.
First Surname
Name
Address
Postcode Telephone
020
Gender Male Female
Date of birth (day/month/year) / / Age
Do you need an Yes What is your first
interpreter? language?
No
Have you used any Age Asian Womens Hoxton Mobile
of the following Concern Advisory Service Health Repair
services before Group Service
Stroke Survivors The Wayside Meals on Wheels
Project Sharp Community
TLC End Centre
Home Care District Day Centre / Social Club
Worker Nurse Luncheon Club
Council / Private
Please put any other services you use?
Company Limited by Guarantee no. 3140955. Registered Charity no. 1054116 amended 18/03/09
We collect information about your ethnic origin to make sure that our services are reaching
everybody in our community How would you describe your ethnic origin?
Please tick 1 category
Caribbean Indian White UK African Pakistani Irish
White and Bangladeshi European White White Other
Black and and White
Caribbean Black Asian backgrou
African nd
Other Other Asian Other Mixed Cypriot Vietnam Jewish
Black Background Parentage ese Orthodox
Backgroun Background
d
Turkish Chinese Jewish Kurdish Greek
Other
Do you have a disability Yes No
Are you registered disabled? Yes No
Have you been bereaved in the last Yes No
18 months
Do you Yes No
live alone
Are you a Yes No
carer
Where did you find out about The Sharp End?
……………………………………………………………
Company Limited by Guarantee no. 3140955. Registered Charity no. 1054116 amended 18/03/09
Incase of an emergency we need to be able to contact
next of kin/friend/ or any person you chose to nominate
Emergency Contact Name………………………………………………..…
How related………………………………………………………………….…
Emergency Telephone Number……………………………………………..
Mobile Number………………………………………………………………….
GP Name ……………………………………
GP Address ……………………………………
Or telephone
……………………………………
……………………………………
…………………………………….
Company Limited by Guarantee no. 3140955. Registered Charity no. 1054116 amended 18/03/09
THE SHARP END PARQ
Do you have any of the following medical/health conditions?
1. Has your doctor ever said that you have a heart condition? YES NO
If YES, have you been told you should only YES NO
do physical activity recommended by your doctor?
2. Do you get pain in your chest when you do physical activity? YES NO
3. Have you had chest pain at rest in the past two months? YES NO
4. Do you suffer from asthma or any other breathing problems YES NO
5. Have you had any serious illness or been in hospital during the past YES NO
2 years?
6. Do you have a bone or joint problem (Osteoporosis/Rheumatoid Arthritis)
that could be made worse by a change in your physical activity YES NO
7. Do you have any replacement joints (e.g. hip replacement)? YES NO
8. Have you fallen in the past year? YES NO
If YES, how many times have you fallen? ……………………
9. Do you lose your balance because of dizziness,
Or, ever lose consciousness? YES NO
10. Do you have heart disease YES NO
11. Do you suffer from Epiliepsy? YES NO
12. Depression/Anxiety YES NO
13. Are you diabetic YES NO
14. High Cholestrol YES NO
Company Limited by Guarantee no. 3140955. Registered Charity no. 1054116 amended 18/03/09
15. Do you take more than 4 medications YES NO
16. Are there any exercise that you Dr/Health professional has advised you against
YES / NO (if YES please state………………………………………………………………)
17. Please tell us anything else that may affect your ability to exercise
(including any operations in the last 18 months)
Assumption of Risk: The information given above is true and I am engaging in
exercise voluntarily and I accept any risks associated with these exercises
Signed:________________________________ Date_______________________
Company Limited by Guarantee no. 3140955. Registered Charity no. 1054116 amended 18/03/09
Health Survey
1. This survey asks for your views about our services and your health. This
information will help us to see if the activity you are doing is of any benefit and
help you keep track of how you feel and how well you are able to do in your
usual activities.
Thank you for completing this survey!
Answer every question by selecting the answer as indicated. If you are unsure
about how to answer a question, please give the best answer you can.
For each of the following questions, please mark an [x] in the one box that
best describes your answer.
Name …………………………………………………………………………….
Date………………………………………………………………………………
Date of birth ……………………………………………………………………
Ethnicity …………………………………………………………………………
1) The Sharp End
2) Overall, how would you rate your health during the past 4 weeks?
Excellent Very good Good Fair Poor Very poor
[ ] [ ] [ ] [ ] [ ] [ ]
3) During the past 4 weeks, how much did physical health problems limit your usual physical
activities (such as walking or climbing stairs)?
Not at all Very little Somewhat Quite a lot Could not do
physical activities
[ ] [ ] [ ] [ ] [ ]
4) During that past 4 weeks, how much difficulty did you have doing your daily work, both at home
and away from home, because of your physical health?
None at all A little bit Some Quite a lot Could not do daily
work
[ ] [ ] [ ] [ ] [ ]
Company Limited by Guarantee no. 3140955. Registered Charity no. 1054116 amended 18/03/09
5) How much bodily pain have you had during the past 4 weeks?
None Very mild Mild Moderate Severe Very severe
[ ] [ ] [ ] [ ] [ ] [ ]
6) During the past 4 weeks, how much energy did you have?
Very much Quite a lot Some A little None
[ ] [ ] [ ] [ ] [ ]
7) During the past 4 weeks, how much did your physical health or emotional problems limit your
usual social activities with family or friends?
Not at all Very little Somewhat Quite a lot Could not do social
activities
[ ] [ ] [ ] [ ] [ ]
8) During the past 4 weeks, how much have you been bothered by emotional problems (such as
feeling anxious, depressed or irritable)?
Not at all Slightly Moderately Quite a lot Extremely
[ ] [ ] [ ] [ ] [ ]
9) During the past 4 weeks, how much did personal or emotional problems keep you from doing
your usual work, school or other daily activities?
Not at all Very little Somewhat Quite a lot Could not do daily
activities
[ ] [ ] [ ] [ ] [ ]
Thank you very much for completing these questions!
Company Limited by Guarantee no. 3140955. Registered Charity no. 1054116 amended 18/03/09
MEMBERSHIP POLICY
Membership Fee
Quarterly term payments £15 for 12 weeks
(4 quarterly terms)
Oct – Dec
Jan – March
April – June
July – Sep
Annual - £50
Membership Payment Options
No contract hassles!
Payment options include: Quarterly or annual
Payment method cash or cheque accepted.
Membership Card
Your membership card is valuable and important. You must keep the card with you as
you will be asked by staff and tutors to produce this in random checks. Lost quarterly
and annual cards can be replaced. Each term the cards will be a different colour.
Membership payment policy in the following situations
If you are away for the whole term you will not need to pay for that term.
Members away for a few weeks during the term will have to pay full term fee
(full 12 weeks)
New members starting mid-term will get a discount for remainder of that term
Once membership has been paid they cannot get refund only in exceptional
circumstances.
Class reservation
If a member will be away for a set time, their space will be kept for three months
only. However, in these instances we need to assess their fitness level to
check that they are able to resume demanding classes,
Company Limited by Guarantee no. 3140955. Registered Charity no. 1054116 amended 18/03/09