FORM | Aqua Health

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Medical form and GDPR Disclaimer

Please take a moment to fill out this form.

Full name

Address

Phone

Birthday

Gender

Please read this carefully. If you are unsure about any aspect of this questionnaire, please ask us for assistance. It is very important that you answer all the questions honestly and accurately and where necessary consulting with your Doctor. How physically fit do you feel you are?

Very fit

Above average

Average

Below average

Do you currently take part in any form of pysical activity? If Yes, please specify:

Are you pregnant?

Do you have any problems with your blood pressure? If yes, please specify.

Do you have a bone or joint problem that could be made worse by physical activity?

Do you have or have you had any of the following (or similar) conditions:

Lower Back Pain

Upper Back Injury

Hip/Pelvis Injury

Head/Neck Injury

Foot/Ankle Injury

Muscular Injury

Arm/Elbow

Nerve Damage

Bone Fracture

Shoulder/Clavicle Injury

Wrist/Hand Injury

Knee Injury

If YES to any of the above, please specify: What caused the pain? How long ago did the injury occur? When do you feel the pain most? (AM, PM or post exercise) Did you have treatment for the injury? Do you have any restrictions?

Do you consider yourself to have any of the following disabilities:

Visual Impairment

Physical Impairment

Multiple Impairment

Hearing Impairment

Learning Disability

Other

If YES to any of the above, please give details:

I will download and print the GDPR form below and will provide a copy to AquaHealth directly.GDPR

GDPR

Select a date

All details I have provided are correct

Thanks for submitting!

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