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Health Declaration Form

Any physical limitations or disabiities:​

Neck / Back aches / Injuries
Joint-related issues
Ligament injuries
Spinal conditions
Bowel/Bladder issues
Communicable disease
Chronic pain
Glaucoma / Retinal Detachment / Eye Surgery
Depression / Psychosis
Respiratory conditions
Heart Conditions
High blood pressure
Low blood pressure
Seizures / Epilepsy
Bleeding disorders
Hospitalization for a psychiatric condition in the past
Any Serious illness in the last three years:
Any Injury in the last three years:
Surgery in the last three years
Psychotherapy, psychological therapy and counseling in the last five years:
For women, Are you currently pregnant or planning for pregnancy?

Thanks for submitting!

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