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Health Declaration

Please fill out the following form
in order to participate in all activities.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Have you ever felt pain in your chest when you do physical exercise?
In the past month, have you had chest pain when you were not doing physical activity?
Do you often feel faint, have spells of severe dizziness or have lost consciousness?
Have you ever suffered from unusual shortness of breath at rest or with mild exertion? you often feel faint, have spells of severe dizziness or have lost consciousness?
Has the doctor ever said that you have a bone or joint problem (such as arthritis) that has been aggravated by exercise or that may be made worse by exercise?
Do you have either high or low blood pressure. If yes, please desribe below.
Are you currently on any prescribed medicines that may affect your ability to exercise?
Are you pregnant or have you had a baby in the last 6 months?
Have you ever suffered from back pain or have any back related illness or injury?

I have been informed both verbally and in writing that if I answer YES to any of questions 1-12 of this questionnaire, I should seek medical advice/approval before commencing an exercise programme and/or induction. If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered the above questions honestly. I understand that the Centre and any of its employees cannot be held responsible for any injuries or ill health arising from my participation in the exercise programme.

Thanks for submitting!

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