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Health declaration
Please fill out the following form.
First name
Last name
Email
*
Date of birth
Month
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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