Boost Health & Fitness Registration Form

* Denotes questions that require an answer

Word of mouth

Brochure or advertising

Passing by

Web search

Media coverage

Other (please specify)

Yes

	Yes	No
A heart condition	A heart condition Yes	A heart condition No
Diabetes - Type 1 or 11	Diabetes - Type 1 or 11 Yes	Diabetes - Type 1 or 11 No
Arthritis	Arthritis Yes	Arthritis No
Asthma	Asthma Yes	Asthma No
High Blood Pressure	High Blood Pressure Yes	High Blood Pressure No
High Cholesterol	High Cholesterol Yes	High Cholesterol No
Epilepsy	Epilepsy Yes	Epilepsy No
Osteoporosis	Osteoporosis Yes	Osteoporosis No
Endometriosis	Endometriosis Yes	Endometriosis No
Have you had any major operations	Have you had any major operations Yes	Have you had any major operations No
Do you ever get chest pains?	Do you ever get chest pains? Yes	Do you ever get chest pains? No
Do you ever feel dizzy?	Do you ever feel dizzy? Yes	Do you ever feel dizzy? No
Do you take any medication?	Do you take any medication? Yes	Do you take any medication? No
Have you smoked in the last 5 years?	Have you smoked in the last 5 years? Yes	Have you smoked in the last 5 years? No

If you have answered "yes" to any of the above questions please give details

If you have answered "yes" to any of the above questions please give details

By ticking this box I have read and agree with the above statement.