› Health Questionnaire

NEW COURSES Triathlon Swim Schools in Ashby and Loughborough starting April 2017

Health Questionnaire

We require any potential clients to be currently in good health and have had no significant injuries in the recent past.  This is to ensure your own well-being.

Please complete the form below.

Please note that all fields followed by an asterisk must be filled in.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Convulsions/epilepsy
Asthma
Diabetes
Heart problems
Chest pain or heart palpitations
Shortness of breath
Unconsciousness or fainting
Numbness in hands or feet
Disturbance of balance/coordination/vision/hearing
Problems with bones, joints or muscles
A blood disorder/virus
Low or high blood pressure
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Please enter the word that you see below.

  

› Health Questionnaire

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