Your name
Age
Date of Birth
Your email
Phone Number
Home Address
GP/Doctor's NAME or Emergency contact NAME *
Emergency contact NUMBER *
Are you currently taking ANY medication? * YesNo
If you are on, or just coming off, medication then please detail below, including any relevant information that may impact your safety.
Are you pregnant or have given birth in the last 3 months? * YesNo
Please detail any specifics regarding pregnancy/birth that may impact your safety
Is there a history of heart problems or chest pain in your family or with you? * YesNo
If yes please detail below
Do you have HIGH OR LOW blood pressure? * Yes (High)Yes (Low)No
Do you have difficulty with physical exercise or advice from your GP to avoid specific movements? *
YesNo
Do you have Diabetes? * YesNo
Do you have any muscle, joint or back disorders that could be aggravated by physical exercise?* YesNo
Have you a recent surgery? (within last 3-6 months?) * YesNo
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