Medical Form Name Email Facebook Name Date of Birth Gender Male Female Contact Phone Number Address Line 1 Address Line 2 Suburb Postcode intraining training group Emergency Contact Name Emergency Contact Number Relationship of emergency contact person Do you have any of the following conditions: Do you currently have any injuries? Yes No Please describe if you answer yes Are you or might you be pregnant? Yes No Please describe if you answer yes Do you have any known heart conditions? Yes No Please describe if you answer yes Do you often feel faint or have spells of severe dizziness during exercise? Yes No Please describe if you answer yes Do you feel unusual fatigue or shortness of breath at rest or with mild exertion? Yes No Please describe if you answer yes Do you experience swelling or accumulation of fluid in or around your ankle? Yes No Please describe if you answer yes Do you regularly get sharp pains in your legs? Yes No Please describe if you answer yes Are you asthmatic? Yes No Please describe if you answer yes Do you have any allergies? Yes No Please describe if you answer yes Do you have Type 1 diabetes? Yes No Please describe if you answer yes Date Form completed Electronic Certification I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge. Submit
