Health Questionnaire Please complete the form below Name * First Name Last Name Email * Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Email * Emergency Contact Phone * (###) ### #### At present, do you have any health problems for which you are on medications or supplements, prescribed or otherwise? * Yes No At present, do you have any health problems for which you are attending your general practitioner? * Yes No In the past two years, have you had any illness which required you to attend a hospital outpatient department? * Yes No In the past two years, have you had any illness which required you to be admitted to hospital? * Yes No Has any, otherwise, healthy member of your family under the age of 35 died suddenly during or soon after exercise? * Yes No Has any, otherwise healthy member of your family under the age of 50 been diagnosed with heart disease? * Yes No Females: Could you be pregnant? * Yes No If you have answered YES to any of the above, please provide details. Have you had any long term injuries? * Yes No If you have answered YES to the previous question, please provide details. Thank you!
