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Sign In
My Account
Cart
0
Evan
Results
Reviews
Instagram
Contact
New Cover Page
par-q form
Name
*
First Name
Last Name
Email
*
Telephone
*
Please detail your medical history in the last 12 months (any operations, illnesses, injuries etc.)?
Do you suffer from allergies? If yes, please give details:
Are you currently taking any prescribed medication? If yes, please give details:
Are you currently receiving treatment from a GP/health professional? If yes, please give details:
Do you currently have any of the following conditions?
Cancer or had cancer in the last 5 years
Diabetes
High/Low blood pressure
Arthritis
HIV/AIDS
Hepatitis
Skin disease
Seizure disorder
Hormone imbalance
Thyroid imbalance
Blood clotting
Liver/Kidney infection
Any active infection
Epilepsy
Fungal conditions
Heart conditions
Infectious diseases
Infectious diseases
Muscular problems
Recent cut/abrasion/bruising/swelling/inflammation
Skin disorders
Thrombosis/varicose veins
Other
Please give details on your condition:
Could you be pregnant?
*
Yes
No
Have you recently consumed alcohol?
*
Yes
No
Have you recently taken un-prescribed drugs?
*
Yes
No
Declaration:
*
“I the above, have completed the form as fully and accurately as I can. I believe the details to be correct and consent to work with the practitioners within Paradox. I release the practitioner/company from any negligent misrepresentation that may be contained in the form. I accept that exercise I participate in is taken at my own risk. I understand that failure to disclose information requested above may result in adverse side effects, unknown because of this to which I accept full liability/responsibility. I am aware that it is my responsibility to inform the practitioner of my current and ongoing medical or health conditions, and it is essential for the caregiver to execute appropriate treatment procedures. I understand Paradox reserves the right to charge for appointments cancelled or broken without 24 hours notice.”
I agree to the above declaration
Date
*
MM
DD
YYYY
Thank you!