Medical Questionnaire – Life Transformer

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Date of birth*

Are you now, or have you ever suffered from any of the following? (please mark below)

Heart conditions
High/Low blood pressure
Back or joint problems
None of the above

Diabetes
Respiratory Illness (asthma, bronchitis, emphysema)
fainting/dizzines
None of the above

Under medical treatment for any illness
Had any serious injury or operation within the last 18 months
Ladies - Are you pregnant
None of the above

If you selected any of the above, please give detail

Do you have any concerns or issues I may need to know about?

What is your training schedule like? How many steps do you take daily?

NEXT OF KIN, NAME & CONTACT DETAILS

If you have answered YES to one or more questions above you should contact your GP to clarify it is safe for you to exercise at this current time. This PARQ becomes invalid if your condition changes at any point and you would answer YES to any of the questions above.*

Tick to confirm you understand