Acquaintance & Medical Course Date: * Course Location: * Given Name: * Surname: * Address: Suburb State: Select State QLD NSW WA VIC SA TAS ACT NT Post Code: Mobile #: * Email * Sex: Male Female Other Date of Birth: Occupation: Emergency Contact Name: Relationship: Mobile #: Email WARNING: Breath-Hold training in an aquatic environment can be hazardous – Please Read This First The aquatic environment i.e. swimming pool, beach pool or ocean, is a dynamic medium that can be physically demanding and mentally challenging. The aquatic environment may expose you to unusual mental and physical stressors in a short period of time that if left unchecked or taken to extremes, may result in injury or death unknowingly. There is also considerable sensory deprivation i.e vision, hearing, touch and balance all of which can be disturbed and restricted and the effects are exacerbated by certain medical conditions. Failure to account for these conditions prior to engaging in Breath Enhancement Training activities may endanger your health, your life, and the safety of any person you may train with. MEDICAL HISTORY QUESTIONNAIRE The purpose of this Medical History Questionnaire is to find out if your doctor should examine you before participating in Breath Enhancement Training (hereafter referred to as B.E.T). Your signature on this statement is required for you to participate in B.E.T programs. A positive response to a question does not necessarily disqualify you from participating, it just means that there is a pre-existing condition that may affect your safety and Equalize Training Company Pty Ltd will advise if you must seek the advice of your physician prior to engaging in our programs (and supply us with a medical certificate). Nevertheless, some medical conditions are too risky and will, consequently, preclude you from participation. Please read the following questions carefully and respond with a YES or NO regarding your past & present medical history, if unsure answer YES. CONDITION - IF YOU ANSWER YES TO ANY QUESTION YOU MUST GIVE A DESCRIPTION. Pregnancy: Pregnant or planning to be pregnant? Yes No Description Neurological: Any history of seizure disorder; convulsions fainting or fits; hallucinations; schizophrenia; brain surgery; stroke, black-outs; severe migraine headaches; aneurysm or brains blood vessels; other Yes No Description Cardiovascular (Heart & Blood) Conditions: Heart attack; heart surgery, irregular heart beat, uncontrolled elevated blood pressure; uncontrolled bleeding or blood disorders; other Yes No Description Asthma: Asthma history or attacks; History of wheezing caused by exercise, cold, anxiety, fatigue etc; Any condition requiring medication and/or use of inhaler to control wheezing; other. Please give details further down. Yes No Description Lungs: Any history of collapsed lungs, spontaneous or by injury: cysts; air pockets; damaged lung tissue, emphysema; any problem that interferes with your ability to breathe Yes No Description Medications: With the exception of birth control or anti-malarial, anything taken on a regular basis either over-the- counter or prescription Yes No Description Diving Accidents: Any history of diving accidents or decompression illness Yes No Description Medical: Any physical and/or emotional condition not mentioned that might affect your safety in an underwater environment or affect your judgement under times of physical or emotional stress Yes No Description Allergies (list): Diabetes: Current or history Description of Medical Conditions and/or Medications: MEDICAL HISTORY DECLARATION This declaration and your responses to the medical questionnaire are a confidential document between yourself and the Breath Enhancement instructor/supervisor. If you have any questions regarding this Medical Questionnaire or the Medical Declaration, review them with a B.E.T staff member before signing. I, the undersigned, hereby affirm that I have read the WARNING section above, I have provided accurate information about my medical history to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. If I suffer from any such condition I have or will seek professionally informed opinion, on these medical conditions, which may predispose me to a greater risk than normal whilst involved in Breath Enhancement Training Signature of Participant Date *Signature of Parent(s)/Guardian(s) if < 18 years of age Date If you are human, leave this field blank. Submit
