Contraindication Form

Email Address
First Name
Last Name
Street Address
Postal Code
City
Date of Birth
Phone Number

Question 1: Do you currently have any acute illnesses or inflammatory processes?YesNo

Question 2: Do you have thrombosis?YesNo

Question 3: Do you currently have fresh wounds or have you had recent surgery?YesNo

Question 4: Have you received a stent (less than 6 months ago)?YesNo

Question 5: Do you have untreated high blood pressure?YesNo

Question 6: Do you have severe diabetes with microangiopathies/gangrene?YesNo

Question 7: Do you have a heart or brain pacemaker?YesNo

Question 8: Are you currently undergoing chemotherapy or cancer treatment?YesNo

Question 9: Do you have epilepsy (seizures within the last 12 months)?YesNo

Question 10: Are you currently pregnant or breastfeeding?YesNo

Question 11: Do you currently have severe circulatory disorders?YesNo

Question 12: Do you currently have a severe neurological disease (brain or nervous system)?YesNo

Question 13: Do you have an abdominal wall or inguinal hernia?YesNo

Question 14: Do you currently have tuberculosis (lung infection)?YesNo

Question 15: Do you have bleeding or severe bleeding tendencies (hemophilia)?YesNo

Question 16: Do you currently have acute back pain?YesNo

Question 17: Do you have cardiovascular diseases (heart or vascular system)?YesNo

Question 18: Do you have bleeding or severe bleeding tendencies (hemophilia)?YesNo

Question 19: Do you have epilepsy (at least 12 months without a seizure)?YesNo

Question 20: Do you experience motion sickness (kinetosis)?YesNo

Question 21: I am mainly interested in the following areas:
Muscle Building
Weight Reduction
Back Training
Pelvic Floor Training
Postnatal Recovery

Question 22: Profession?

Question 23: % sedentary activity?

Question 24: Hobbies?

Question 25: Do you take any medications?YesNo

If yes, which ones?

Question 26: Have you had surgery in the last 2 years?YesNo

If yes, when and for what reason?

Question 27: Do you have problems in specific body regions/joints?

Question 28: I am interested in corporate fitness training through Wellpass/Egym or Wellhub.YesNo

Question 29: Additional Information

Question 30: How did you hear about us?:
Google
Facebook
Instagram
Newspaper
Other
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