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Health declaration

Please fill out the following form.

Date of birth
Day
Month
Year

Have You Prevously or Do You Currenly Experience....

Diabetes or any other metabolic disorder
Hypertension (High Blood Pressure)
Hypotension (Low Blood Pressure)
Cardiac (Heart) Issues Or Chest Pain
Any neurological disorders? (eg. Epilepsy)
Feeling, Faint, Light Headed Or Dizzy
Bone Or Joint Problems
Hypermobility
Are you pregnant or have given birth in the last six months?
Do You Currently Smoke Or Vape?
Have you been hospitalized in the last 12 months?
Ye
No
Are you suffering from any medical condition, illness or injury? (That you haven’t already stated above)
Ye
No
Are you aware, through your own experience or a doctor’s advice, of any other physical reason against your exercising without medical supervision?
Please confirm that by attending any of our sessions you are aware that you do so at your own risk.
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Based between Dorking, Surrey & Hove, East Sussex  Info@meiam.com

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