Health questionnaire

Name *

First Name

Last Name

Have you ever suffered from a heart condition and been advised only to exercise under medical supervision *

Yes

No

Do you currently or have you ever suffered from chest pains?

Yes

No

Have you ever had asthma, chronic bronchitis or any other chest ailments?

Yes

No

Do you ever suffer from dizziness or feel faint? *

Yes

No

Have you ever had high or low blood pressure and/or high cholesterol? *

Yes

No

Are you presently taking any form of medication? *

Yes

No

Do you suffer from back pains or any other bone or joint problems (such as bad knees)? *

Yes

No

Are you recuperating from a recent illness, injury or operation? *

Yes

No

Have you any medical condition I should be aware of? (e.g diabetes, asthma, epilepsy) *

Yes

No

Have you ever experienced, or receive treatment for POP (pelvic organ prolapse)? Or have any concerns over your pelvic health?

Yes

No

Are you pregnant or have you given birth in the last 6 months? *

Yes

No

Signature *

I confirm that I have read, fully understood and answered the questions honestly.

First Name

Last Name

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