Health Declaration

Please fill out the following form

Full Name

Date of Birth

Code

Phone

Email

Occupation

Address

Doctors Address

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Have you had any recent surgery or chemotherpy in the last 6 months(plese specify where)

Any Known allergies

Are you taking medication

Please mark any conditions that applies * Required

Arthritis

Diabetes

Low blood pressure

High Blood Pressure

Fibromylgia/Chronic Fatigue

Varicose Veins

Blood Clots

Cancer

Frequant Headaches

Osteoporosis

inflammation / Swelling

Chronic Back / Neck Pain

Cardiac/ Circulatory Problems

Any Skin Conditions

Scoliosis

None of these

Would yopu like to recevie any infromation on promotions

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!

Company Registration No: 13342216

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