Health Waiver

First name

Last name

Phone

Address

Birthday

Day

Month

Year

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 chest

Difficulty breathing or chronic cough

Stomach or duodenal ulcer

Kidney or liver 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 in 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? Provide details*

Are you taking any prescribed medication? Provide details*

Are you pregnant?*

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

Do you have any diet requirements, allergy's or intolerances? Provide details*

I am over 18 years of age or the parent/guardian of member under 18 years of age

I declare that the information provided is accurate and complete

Date

Day

Month

Year

Signature

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