Health Waiver

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First Name

Email Address

Last Name

Phone

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Do you have or have you had any of the following

Any heart attack, stroke or stroke condition

High blood pressure

Pain or tightness in the chest

Difficulty in breathing or chronic coughing

Stomach or duodenal ulcer

Liver or kidney conditions

Diabetes

Hernia

Epilepsy or fits

Dizziness and/or fainting

Back problems

Asthma and/or wheezing

Glandular fever

Gout

Rheumatic fever

Heart murmur

Raised cholesterol

Given birth less than 13 weeks ago

Lost consciousness nin the last 12 months

Have any family members (including grandparents, parents and siblings) had any heart problems prior to the age of 60?

Have you ever had any injury, illness, back or joint condition that may be aggravated by vigorous exercise?

Are you taking any prescribed medication?

Are you pregnant?

Do you have any other medical condition that should be made known?

Do you have any diet requirements, allergys or intolerances?

I declare that the information I have provided is accurate & complete

I agree to the Indemnity and ReleaseView Indemnity and Release

I accept terms & conditionsView terms and conditions

I am over 18 years of age

I would like to recieve newsletters

Initials

Today's Date

Your Signature

Thanks for submitting!

ABN: 17 126 383 030

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