Assess your health by circling "Yes" or "No"

Your health history – Have you ever had or experienced any of these symptoms?

• A heart attack Yes or No
• Heart Surgery Yes or No
• A pacemaker Yes or No
• Heart failure Yes or No
• Heart valve disease Yes or No
• A heart transplant Yes or No
• Congenital heart disease Yes or No
• Chest discomfort with exertion Yes or No
• Unreasonable breathlessness Yes or No
• Dizziness, fainting, blackouts Yes or No
• Any musculoskeletal problems Yes or No
• Eating Disorder Yes or No
• Mind unwellness Yes or No

Please tell me of any other health related information

• Do you take prescription medication Yes or No
• Do you take any heart medication Yes or No
• Are you pregnant Yes or No
• Are you trying to conceive Yes or No

If answered YES to any of the questions please describe

Assess your cardiovascular risk by circling "Yes" or "No"

• Are you a male over 45 or female over 35? Yes or No
• Are you postmenopausal? Yes or No
• Are you a smoker? Yes or No
• Do you have a BP> 140/90mmHg? Yes or No
• Do you take BP medication? Yes or No
• Do you have cholesterol > 240mg/dl? Yes or No
• Do you have a family history of heart attack? Yes or No
• Are you diabetic? Yes or No
• Are you physically inactive? Yes or No
• Do you have epilepsy? Yes or No
• Do you have asthma? Yes or No
• Have you ever had a stroke? Yes or No
• Have you ever had gout? Yes or No
• Have you ever had hernia? Yes or No

If answered YES to any of the questions please describe

How would you prefer to pay for your enarji sessions?

Visa Mastercard Bank Transfer

Good on you, you have taken the first step to enarjizing your life. Your card will be ready for you to collect at your very first enarjize Us session.

Statement

I am aware that my Health Coach is not accredited to provide me with medical advice in relation to my medical fitness. Information that I have provided is used as a guideline to the limitations of my ability for any physical activity. I am aware that I may experience some muscle soreness up to two days after any training session. Whilst every precaution is taken there can be some form of injury such as sprains or muscle strains. If I experience any difficulties whilst training, I am to cease activities immediately & inform my Health Coach. Even though I am training in a safe & controlled environment, I am still responsible for my own safety and wellbeing. I have answered all questions on this medical questionnaire to the best of my ability.

Enter Verification Code: