Name * First Name Last Name Phone * Email * Date of Birth * MM DD YYYY Occupation * Referred By * Next of Kin * Full Name | Relationship | Contact Number What are the 3 major issues facing you? * MEDICAL HISTORY Do you have any current illness or conditions that may restrict your level of physical activity in the program? * Yes No Are you being treated by a medical professional? * Yes No Are you taking anti -depressants medications? * Yes No Have you been under psychiatric care? * Yes No If you answered YES to any of the above please specify more details on what you are treated with and when. Please tick if you have experienced any of the following health conditions. * Please seek medical advice if you have any of the above health conditions Manic Depression Recent Surgery Asthma (medication present) Depression Emphysema Head injuries Heart disease Schizophrenia Mental illness Blood Pressure (High) Epilepsy Kidney Lung weakness Thank you for submitting your form - we will be in touch with you shortly. Client History Form