Purple Freesia Health QuestionnaireAll fields are required, unless otherwise specified. Your Name Your Email Phone Address Date of Birth Your Blood Group (if known) Emergency Contact Name Emergency Contact Number Your Doctor's Name Doctor's Contact Number Have you ever been diagnosed as having a heart problem? NoYes If yes, please provide details: Have you ever been diagnosed has having high blood pressure or circulatory problems? NoYes If yes, please provide details. Have you ever been advised not to exercise?NoYes If yes, please provide details. Have you ever been diagnosed as having asthma or any other respiratory condition? NoYes If yes, please provide details. Have you ever been diagnosed as having diabetes? NoYes If yes, please provide details. Have you ever been diagnosed as having epilepsy? NoYes If yes, please provide details. Is there any other condition that may affect your ability to exercise or receive manual treatment? NoYes If yes, please provide details. Are you currently taking any prescribed medication? NoYes If yes, please provide details. Are you pregnant or have you had a baby in the last 2 years? NoYes If yes, please provide details. Have you had any surgery in the last 5 years? NoYes If yes, please provide details. Have you ever had any digestive or elimination problems? NoYes If yes, please provide details. Have you ever experienced any sensory problems? (eyesight, hearing, balance etc.) NoYes If yes, 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. (Optional.) I have read, understood, and completed this questionnaire and agree to be bound by its conditions.Signature Date
