Healthy Back Classes Enrolment Form

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General Medical Information

Do you have Diabetes?
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If yes, please indicate whether IDDM or NIDDM (diet or medication controlled), also are your glucose levels normalised?
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Is your blood pressure?
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If high, is it stabilised with medication and do you have medical clearance to exercise?
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Do you suffer from Cardiac/heart problems or angina?
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If yes, do you have medical clearance to exercise?
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Do you suffere from any vascular conditions or diseases (DVT, aneurysm, etc)?
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If yes, please give details below and do you have medical clearance to exercise?
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Do you suffer from Epilepsy?
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If yes, have your seizures been stabilised wih medication?
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Do you suffer from Asthma or other breating problems?
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If yes, do you require medication during exercise?
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Do you suffer from digestive complaints (ulcers, reflux, colitis, etc)?
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If yes, please give details:
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Have you noticed any bowel or bladder dysfunction?
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If yes, please give details:
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Have you noticed any recent unexplained weight loss?
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If yes, please give details:
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Have you ever been diagnosed with any form of cancer?
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If yes, please give details:
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Do you suffer from any neurological condidtions or diseases?
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If yes, please give details:
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