Membership Form

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Emergency contact details *

First Name

Last Name

Emergency contact phone number *

Country

(###)

###

####

Do you have any allergies (e.g., medications, foods, environmental) *

Yes

No

Medical History *

Do you have or have you ever had any of the following? (Please tick all that apply)

Asthma

Diabetes (Type 1 or Type 2)

High blood pressure

Heart disease

Stroke

Cancer

Mental health conditions

Other

N

Do you take any regular medications? *

Yes

No

Do you take any regular medications? *

Yes

No

Family medical history *

Do any close relatives (parents, siblings, grandparents) have a history of the following conditions? (Please tick all that apply and specify the relative)

Heart disease

Diabetes

Stroke

Cancer

Mental health conditions

Other

Surgical history *

Have you had any surgeries or hospital admissions?

Yes

No

Consent and declaration *

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that this information will be used to provide appropriate medical care.