Name *

First Name

Last Name

Please indicate any of the following which apply to you:

Please tick

Pregnancy

Cardio vascular conditions

Haemophilia

Any condition already being treated by a GP or professional

Medical oedema

Osteoporosis

Arthritis

Nervous/Psychotic conditions

Epilepsy

Recent operations

Diabetes

Any dysfunction of the nervous system (e.g. Muscular sclerosis)

Bells Palsy

Cancer

Spastic conditions

Kidney infection

Undiagnosed pain

When taking prescribed medication

Acute rheumatism

Please select I ACCEPT if you agree that: *

· You have read, understood and answered honestly the questions in this questionnaire. · You represent that you are medically and physically able to safely participate in the services and meet the physical demands thereof. · You assume all risks associated with your participation in the services. · If at any time hereafter you have any medical or physical limitation or condition that might affect your ability to safely participate in the services or meet the physical demands required thereof, you will make such limitations and conditions immediately known to GPT.

I ACCEPT