Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DOB *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

Country

(###)

###

####

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

No

Yes

Have you ever felt pain in your chest when you do physical activity or at rest? *

No

Yes

Is there any history of coronary heart disease in your family? *

No

Yes

Has your doctor ever said that you have a bone or joint problem, such as arthritis, or any medical condition, surgical operation or injury that has been aggravated by physical activity or might be made worse with exercise? *

No

Yes

Do you frequently feel faint, or have spells of dizziness or lose consciousness? *

No

Yes

Have you ever suffered from unusual shortness of breath at rest or with mild exertion? *

No

Yes

Are you, or is there any possibility that you might be, pregnant? *

No

Yes

Are you currently being prescribed any medication by the doctor? *

No

Yes

Do you know of any other reason why you should not do physical activity? *

No

Yes

Agreement *

If you answered "Yes" to one or more of the questions, please consult your doctor before undertaking any physical activity in connection with Mocean Fit. Your doctor needs to advise you as to your suitability for unrestricted physical activity. If you answered "No" to all questions, you acknowledge that you are taking responsibility for the accuracy of your replies and the decision that you are physically fit. By submitting this Health Questionnaire I undertake that I have read, understood and correctly answered the questions set out above. I wish to participate in physical activities that may include but shall not be limited to aerobic, anaerobic, flexibility, stability, resistance, muscular strength and endurance exercise. I realise that my participation in these physical activities involves the risk of injury and I release Mocean Fit from any liability with respect to any damage or injury which I may suffer whilst exercising. I confirm I am voluntarily engaging in a level of physical activity that I consider acceptable and appropriate to my level of fitness and overall health. I know of no reason why I should not exercise and confirm that I take part of my own free will. I understand that I should only exercise when I feel well and that I must notify any changes in my health to my Mocean Fit. If I have answered ‘yes’ to any of the questions above, by submitting this form I am also confirming that I have taken medical advice relating to my participation and my doctor has confirmed I am fit

I understand the above and confirm that all information provided is correct and up to date to the best of my knowledge.

Today's Date *

MM

DD

YYYY