EFF BOOTCAMP TYGERVALLEY – INDEMNITY & HEALTH SCREENING SIGN UP FORM Name* First Last Date of Birth* DD slash MM slash YYYY Cell*Email* Referred by*Referred byCurrent EFF Boot Camp MemberFriend/FamilyFacebookInstagramWebsitePass ByEmailEmergency Contact Name First Emergency Contact Cell NumberFamily History1. Do you have a family history (parent or siblings) of heart of metabolic disease?* No, non apply High Cholestrol Stroke Non-Insulin Dependent Diabetes High Blood Pressure Insulin Dependent Diabetes Heart Disease Personal Medical History2. Have you ever suffered from any heart, respiratory or metabolic condition?* No, non apply High Cholestrol Stroke Non-Insulin Dependent Diabetes High Blood Pressure Insulin Dependent Diabetes Heart Disease Cancer Other Lung Disease Asthma Peripheral Vascular Disease (Inflammations in the veins) 3. Do you currently experience any symptoms of respiratory or cardiovascular disease?* No, non apply Chest Pain Palpitations Ankle Swelling Intermittent Claudication (Leg cramps during walking) Frequent fainting or Dizzy Spells Shortness of Breath 4. Do you currently experience any general medical symptoms?* No, non apply Flu-like Symptoms Other Significant Symptoms 5. Do you currently suffer from any symptoms of joint injury or joint disease?* Yes No 6. Are you currently pregnant?* Yes No Risk Factors7. Are you a current smoker or have you smoked within the last 6 months?* Yes No 8. Do you do less than 3 hours of physical activity per week? (Including housework, gardening etc.)* Yes No * I have read and accept the Terms and Conditions MEMBERS’ SIGNATURENameThis field is for validation purposes and should be left unchanged. Δ EFF BOOTCAMP 2020 | INDEMNITY RELEASE TERMS & CONDITIONS
