STUDENT HEALTH QUESTIONNAIRE CLIENT CONTACT INFORMATION First Name Last Name Date of birth MM DD YYYY Address Email EMERGENCY CONTACT INFORMATION First Name Last Name Relationship to you Contact number (###) ### #### Email MEDICAL HISTORY Have you had an injury in the last 5 years? Yes No Are you taking any prescribed medication? Yes No Are you receiving treatment for any diagnosed medical conditions? Yes No Have you had any recent operations? Yes No MEDICAL CONDITIONS Please tick if you have any of the following: Abdominal disorder or recent surgery Arthritis (osteoarthritis or rheumatoid arthritis) Back pain or spinal problems Spinal injury Joint replacement Knee problems Hip problems Shoulder problems Neck problems Heart disorders High blood pressure Low blood pressure Other symptoms Please tick if you have any of the following: Unusual shortness of breath with light exertion Pain, pressure, heaviness, or tightness in the chest area Unexplained pain in the abdomen, shoulders, or arms Severe dizzy spells or fainting episodes Regular lower leg pain during walking that is relieved by rest Palpitations or irregular heartbeats Are you currently pregnant, or have you given birth in the last 6 months? Yes No STUDENT DECLARATION I confirm that I have answered all questions honestly and to the best of my knowledge. I understand it is my responsibility to inform Haseya if any of the above information changes. First Name Last Name Date MM DD YYYY Thank you! CONTINUE TO BOOKING
