Purple Freesia Health Questionnaire

Name *

First

Last

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth

Emergency Contact Name

First

Last

Emergency Contact Number

Blood Group (if known)

Doctor's Name

First

Last

Doctor's Contact Number

Have you ever been diagnosed as having a heart problem?

Please provide details.

Have you ever been diagnosed has having high blood pressure or circulatory problems?

Please provide details.

Have you ever been advised not to exercise?

Please provide details.

Have you ever been diagnosed as having asthma or any other respiratory condition?

Please provide details.

Have you ever been diagnosed as having diabetes?

Please provide details.

Have you ever been diagnosed as having epilepsy?

Please provide details.

Is there any other condition that may affect your ability to exercise or receive manual treatment?

Please provide details.

Are you currently taking any prescribed medication?

Please provide details.

Are you pregnant or have you had a baby in the last 2 years?

Please provide details.

Have you had any surgery in the last 5 years?

Please provide details.

Have you ever had any digestive or elimination problems?

Please provide details.

Have you ever experienced any sensory problems? (eyesight, hearing, balance etc.)

Please provide details.

I acknowledge that: *

I do hereby waive, release and discharge Purple Freesia from any and all responsibility or liability for injuries or damages resulting from my treatment or my use of facilities in the above mentioned activities.
I have completed this questionnaire to the best of my knowledge and belief.
I agree to receive the Purple Freesia newsletter, offers and promotional emails from Lynne Snook.

Signature *

I have read, understood, and completed this questionnaire and agree to be bound by its conditions.

Date *