6 week - Online Tailored Program - Cardiac and Diabetes Program

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Athlete/Client 1 Details
Username Password
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If you do not have a username and password, one will be created for you when you submit this form.
Athlete/Client First Name: Mother's Name:
Athlete/Client Last Name: Mother's Email Address:
Date of Birth: Mother's Mobile/Cell:
Gender: Male Female Father's Name:
Email Address: Father's Email Address:
Confirm Email Address: Father's Mobile/Cell:
Home Phone: Do you have any injury concerns?
Mobile/Cell:
Address 1:
Address 2: Do you have any medical conditions?
Suburb/Town:
State/Prov:
Zip/Postcode:
Sport (if applicable):
How did you hear about us?

Training Dates: From 29-May-2017 To 06-Oct-2018

DISCLAIMER:
You are entering into an agreement for a 6 week Online - Trial program only. As part of this program, Vector Health needs to ensure that you are fit to exercise, so part of this form is a questionnaire to assess your risk of cardiac illness prior to exercising. We may ask you for more information and possibly a clearance from your GP to begin exercising as part of this program. As part of this program, you will be provided access to an online program to complete. Please advise us of any illnesses, or injuries during the program so we can adjust your exercise routine.

I agree :
Date: 15-Dec-2017
There are no refunds for any enrolments into Vector Health related programs. When you sign/tick confirmation for this enrolment you are acknowledging that you know this as a fact and have accepted it as a condition.
Payment Method:
Cost: $249.95
Total Cost: $249.95
Credit Card: PayPal

03. ASSESSMENT. 01. APSS Screening Tool

COMPULSORY Adult Pre-Exercise Screening Tool - STAGE 1 only. This questionnaire determines a level of health risk. It is very important that you are upfront and honest with your answers. Answering NO to any of these questions does not mean you cannot do exercise, however it does mean that you present with a risk factor for injury or illness during or post physical activity or exercise.

* Who is your normal General Practitioner?

* What medical Clinic is your General Practitioner from?

* Has your doctor ever told you that you have a heart condition or have ever suffered a stroke?

Yes
No

* Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise

Yes
No

* Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Yes
No

* Have you had an asthma attack requiring immediate medical attention at any time over the past 12 months?

Yes
No

* If you have diabetes (Type I or type II) have you had trouble controlling your blood glucose in the last 3 months?

Yes
No

* Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?

Yes
No

* Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise

Yes
No
  
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