Your name *

First Name

Last Name

Phone *

(###)

###

####

Date of birth *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Emergency Contact Number *

(###)

###

####

Hypertension *

Yes

No

Heart Disease (Angina) or other heart conditions. *

Yes

No

Have you had a heart attack? *

Yes

No

If yes, when

MM

DD

YYYY

Epilepsy *

Yes

No

Diabetes *

Yes

No

Stroke (cva) *

Yes

No

Cancer Treatment *

Yes

No

Detached Retina *

Yes

No

Menier’s Disease *

Yes

No

Multiple Sclerosis (MS) *

Yes

No

Myalgic Encephalomyelitis (ME) *

Yes

No

HIV positive *

Yes

No

Asthma *

Yes

No

Varicose veins *

Yes

No

Allergies *

Yes

No

Currently Pregnant *

Yes

No

Had a baby in the last 6 months? *

Yes

No

Any other illness or medical conditions? *

Yes

No

Have you had structural damage to your body, please tick and provide more details below *

None**

Neck

Back

Shoulder

Hip

Knee

Ankle

Wrist