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Straggtri Health Form 2017/2018
This is form is to assess your Physical Actvity Readiness.
Please answer all the questions
FIirst Name *
Your answer
Second Name *
Your answer
Email Address *
Your answer
Date *
MM
/
DD
/
YYYY
Have you ever sought medical advice for a heart condition? *
Do you experience chest pains? *
In the past month, have you experienced a pain in your chest when you were not doing physical activity? *
Do you ever lose your balance because of dizziness or do you ever lose conciousness? *
Do you have a bone or joint problem? *
Do you have low or high blood pressure *
Are you pregnant? *
Are you diabetic? *
Are you asthmatic? *
Have you had an injury in the last 6 months? *
Do you know of any reason why you should not increase your physical activity? *
Clicking the checkbox next to the following statement is an acceptance of that statement. *
Required
Other information
Do you regularly use a gym or exercise *
Currently, how many times per week do you exercise *
Are you a paid up member of The Stragglers Running Club *
Required
Emergency Contact
Please supply a name and phone number of a person who we can contact in case of emergency
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
PLEASE ADVISE THE COACH OF ANY OTHER CONDITIONS YOU FEEL THEY MIGHT NEED TO KNOW
This information will be kept for Stragglers triathlon health records only. By submitting this form you are acknowledging that you are providing accurate information about your suitability to take part in Stragglers Triathlon activities, but that it is your responsibility to monitor your physical condition on a daily basis and seek medical advice when necessary
Disclaimer *
Required
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