First Name (required)
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Have You Had Surgery in the Last 10 Years?
Have you suffered, or do you suffer, from any of the following:
AsthmaDiabetes (Type 1/Type 2)EpilepsyHigh/Low Blood PressureFainting/Dizziness/HeadachesHeart ConditionHearing Loss
ArthritisBack ProblemsHip ReplacementKnee ReplacementShoulder ProblemsOther Joint Problems
Are You Pregnant?
Any Other Conditions That May Affect Your Ability To Exercise in a Group?
I acknowledge that I am fully responsible for:
monitoring my capability to participate in any exercise session
advising ActiveQi of any health or medical conditions that may affect my participation
I have answered the questions accurately and to the best of my ability:
I understand the questions on this form: