Medical History Questionnaire Trial Session First Name: Middle Name: Last Name: Gender: M 1 F Birthday: _!_1_ Age: Mobile phone: Home phone: Work phone: Email: Adress: City: Country: Emergency Contact Information: Name: Relationship: Phone: Email: How did you heard about us? Contra-indicators Miha Bodytec 1. Do you suffer from epilepsy? (brain disorder) no_ yes 2. Do you suffer from acute thrombosis? (heart disease) no_ yes 3. Do you use a pacemaker? (device used to heart) no_ yes 4. Do you suffer from serious medical conditions like cancer or MS? (Disease attacks the central nervous system) no_ yes 5. Are you pregnant? no_ yes 6. Dou you suffer from severe circulatory disorders? (Problems to heart, flood vessels) no_ yes 7. Do you suffer from tuberculosis? (bacteria to lungs) no_ yes 8. Do you suffer from severe neurological disorders? (Disorder to brain 8 spinal cord) no_ yes 9. Do you suffer from Diabetes mellitus? (high sugar) no_ yes 10. Do you suffer from bleeds? (Hemophilia) no_ yes 11. Do you suffer from abdominal or inguinal hemia? (Tissue through abnormal opening) no_ yes Do you have any problems with your joints at the moment? no_ What Is/are your goals/s? On which area you would like to focus on? Place, Date, Signature: Yee n u wunuteS Personal Fitness Training Al Badaa Town Houses, Al West Road. Jumeirah 1 Dubai. U.A.E. www.my30minutes.com Seite 1 von 3 EFTA01112024