Health Declaration

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First Name

Last Name

Email

Have you experienced any of the following:

Heart attack

Heart palpiltations

Chest discomfort with extertion

Breathlessness

High or low blood pressure

Epilepsy

Diabetes

Asthma

Stroke

Over or under active thyroid

Back pain/injury

Surgery

Take prescription medications

Where did you hear about us?

Other (please specify)

Date

Initials

I confirm that the information given in this form is true

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