📑 Medical form

First and last name*

Email*

1. I have had problems with my lungs/breathing, heart, or blood.*

Yes

No

2. Am I over 45 years old?*

Yes

No

3. It is difficult for me to perform moderate exercise (for example, walking 1.6 kilometers/one mile in 12 minutes or swimming 200 meters/yards without resting), or I have been unable to participate in normal physical activity due to fitness or health reasons in the past 12 months.*

Yes

No

4. I have had problems with my eyes, ears, or nasal passages/sinuses.
*

Yes

No

5. I have had surgery in the last 12 months, or I have ongoing problems related to a previous surgery.*

Yes

No

6. I have lost consciousness, had migraine headaches, seizures, a stroke, a significant head injury, or have suffered from a persistent neurological injury or illness.*

Yes

No

7. I have had psychological problems (or received psychological treatment within the last 5 years), been diagnosed with a learning disability, personality disorder, panic attacks, or an addiction to drugs or alcohol.*

Yes

No

8. I have had back problems, a hernia, ulcers, or diabetes.*

Yes

No

9. I have had stomach or intestinal problems, including recent diarrhea.*

Yes

No

10. I am taking prescription medications (with the exception of contraceptives or anti-malarial medications other than Lariam-mefloquine).*

Yes

No

Date of birth*

Please read and accept the participant statement below with your signature. Participant Statement: I have answered all questions honestly, and I understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for failing to disclose any existing or past health conditions

In case you need equipment rental, please indicate your height and weight for the appropriate sizes.

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