Medical Screening Form Step 1 of 3 33% General InformationName* First Last Date Of Birth* Email* Mobile Phone*Address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Medical InformationHas your doctor ever advised you not to participate in physical activity without their recommendation ?*YesNoFurther details*Do you suffer from, or have you suffered from any of the following conditions*Angina, Heart attack, Other heart condition, Chest pains, Breathlessness, Stoke, Asthma, Diabetes, Epilepsy, Allergy, Dizziness, Loss of consciousness, Arthritis, Cholesterol problems, Blood pressure problems or Bronchial problems.YesNoFurther details*Do you have any pain / complaint in the following areas*Feet, Ankles, Lower leg, Knees, Upper legs, Hips, Back, Shoulders, Neck, Head, Elbows, Hands or anywhere else?YesNoFurther details*Have you had any sprain or strain injury in the last 18 months?*YesNoFurther details*Does exercise aggravate any condition or injury*YesNoFurther details*Is your doctor currently prescribing you any medication?*YesNoFurther details*Are you pregnant or have you given birth in the last 6 weeks?*YesNoDo you know of any reason why you should not participate in any physical activity?*YesNoFurther details* DECLARATION I have read and understood the questions in this form and have answered them honestly and to the best of my knowledge. I understand that if I have answered yes to any of the questions in this form then I will need to discuss the details with my personal trainer and may be asked to talk with my doctor before commencing a fitness programme. I agree to inform my personal trainer should my health change so that I can answer yes to any of the above questions. Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.