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Patan, Lalitpur, Nepal
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Membership Form
MEMBERSHIP FORM
First Name:
Middle Name:
Last Name:
Date of Birth
Address:
Email:
Contact:
Sex
Choose
Male
Female
Others
Current Weight:
Height:
Emergency Contact:
Relationship:
Medical Questionaire
Have you ever or do you have any of the following?
Dizziness
Fainting
Epilepsy
H/L Blood Pressure
Diabetes
Asthama
Arthritis
Others
Do you have any problems injuries in following areas
Knees
Lower back
Neck/Shoulder
Hip
Others
Are you currently doing any regular physical activity, what & how many times per week?
Are you had surgery in last 5 years. if yes when & what?
Anything else we need to know ? (if unsure write it down):
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