Adult Health and Medical Screening
Please review and complete
Personal Details
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Details
Emergency Contact Full Name
*
Emergency contact - Relationship
*
Emergency Contact - Phone Number
*
-
Area Code
Phone Number
Medical History
Do you have any current or past medical conditions?
*
Yes
No
Have you experienced any of the below (tick all that apply)
Blood pressure issues (high or low)
Chest pain, dizziness or fainting during exercise
History of joint or bone problems (arthritis, fractures etc)
Allergies (food, medical, environmental)
Pregnancy / recently given birth
If you ticked yes to any of the above, please provide relevant detail below:
Do you take any medication?
*
Yes
No
If yes, please list below:
Fitness Readiness
Do you feel capable of strenuous physical activity?
*
Yes
No
If No, please detail any concerns below for discussion:
Have you been advised to avoid certain activities?
*
Yes
No
If yes, please detail below:
Consent and Acknowledgment
Please tick
*
I declare that the information provided is accurate and complete
I acknowledge the risks of participation
I authorise Dynamic Edge staff to seek emergency medical treatment if required.
Name
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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