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Health declaration

Please fill out the following form.

Date of birth
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
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