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Medical Registration Form
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Name
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Last
Email
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Contact Number
Date of Birth
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Height (cm)
Weight (kg)
Emergency Contact Name
Relationship
Emergency Contact Address
Emergency Contact Phone
Next
Are you currently under a doctor's care?
Yes
No
If yes, explain
When was the last time you had a physical examination?
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MM
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YYYY
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Physician
Specialty
Address
Phone
Previous
Next
Have you ever had an exercise stress test?
Yes
No
Don't Know
If Yes, were the results
Normal
Abnormal
Do you take any medications on a regular basis?
Yes
No
Don't Know
If yes, please list medications and reasons for taking
Have you been recently hospitalized?
Yes
No
Don't Know
If yes, explain
Previous
Next
Do you smoke?
Yes
No
Are you pregnant?
Yes
No
Do you drink alcohol more thant three times/week?
Yes
No
Is your stress level high?
Yes
No
Are you moderately active on most days of the week?
Yes
No
Do you have High blood pressure?
Yes
No
Previous
Next
Do you have High cholesterol?
Yes
No
Do you have Diabetes?
Yes
No
Have parents or siblings who, prior to age 55 had
Yes
No
A heart attack?
Yes
No
A stroke?
Yes
No
High blood pressure?
Yes
No
hospitalized? week? Weight
Previous
Submit