PD WARRIOR WAIVER
Please complete this form to ensure your safety and to help you understand any risks that may arise from doing a PD Warrior exercise.
Patient's Name
First Name
Last Name
Age
Gender
Male
Female
Other
E-mail
Location
Country
City
Emergency Contact Information
Full Name and Relationship
Contact Information
How did you first hear about the online gym?
Tribe 365
10 Week Challenge
Search engine
Social Media
MyParkinson'sTeam Community
Word of mouth/Other Parkinson's community
Other
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BACKGROUND
How many years ago were you diagnosed with Parkinson's?
What type of Parkinson's do you have?
Bradykinesia
Tremor Dominant
Agility Impaired
Combination
I don't know (Please take this quiz to find out www.pdwarrior.com/quiz )
Does your Parkinson's interfere or prevent you from participating in work, hobbies or activities of daily living? If so, what?
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MEDICAL HISTORY
Do you have any of the following? If you answer YES to any of these, please contact us directly to discuss your suitability to start independent exercise (hello@pdwarrior.com)
*
Rows
Yes
No
N/A
Unstable heart condition
Respiratory condition
Fall or 'near miss' in the past three months
Freezing of gait limiting mobility
Dizziness or vertigo
Other neurological condition
Recent surgery, injury or persistent pain
Epilepsy
Current cancer requiring treatment
Pregnancy
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