First Name (required)
Last Name (required)
Your Email (required)
Have You Had Surgery in the Last 10 Years?
YESNO
Have you suffered, or do you suffer, from any of the following:
AsthmaDiabetes (Type 1/Type 2)EpilepsyHigh/Low Blood PressureFainting/Dizziness/HeadachesHeart ConditionHearing LossMental Health Issues
Do you have restricted movement?
Parkinson'sArthritisBack ProblemsJoint ReplacementShoulder ProblemsWheelchair UserOther Joint Problems
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:
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