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

If yes please detail below

Do you have Diabetes? *
YesNo

Do you have any muscle, joint or back disorders that could be aggravated by physical exercise?*
YesNo

If yes please detail below

Have you a recent surgery? (within last 3-6 months?) *
YesNo

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