Health declaration

Please fill out the following form.

First name

Last name

Email*

Date of birth

Month

Day

Year

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

Have you felt chest pain due to exercise?

No

Yes

Do you lose balance due to dizziness, or ever lost consciousness?

No

Yes

Do you take any medications regularly?

No

Yes

Have you, or a family member suffered a stroke, or heart attack?

No

Yes

Are you pregnant now, or have you given birth in the past 6 months?

No

Yes

Do you know of any other reason why you shouldn't engage in physical activity?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Initials*

I declare that the info I’ve provided is accurate and complete.

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