Thank for for joining up to Felda

Please complete the new members screening form below :-

Contact Info

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Health Info

Please answer the following questions by circling the appropriate response:

Do you suffer/have ever suffered from any of the following conditions?

Heart Disease / Chest Pain : *
Heart disease / Chest pain when exercising
High or low blood pressure : *
High or low blood pressure
Heart Disease or Stroke : *
History of heart disease or stroke in your family (before 55 yrs)
Asthma or lung problems : *
Diabetes : *
Thyroid Condition : *
Epilepsy *
Hernia : *
Muscle joint or back pain : *
Taking Medication *
Are you currently on any type of medication
Pregnant Status - are you/ have you been pregnant in the last 6 months? *
Are you or have you been pregnant in the last 6 months
Surgery Status : Have you had any surgery in the last 6 months ? *
Have you had any surgery in the last 6 months
Doctors Advise Against Exercise *
Have you ever been advised by a doctor not to exercise
Limited Ability : *
Do you have any other condition which may limit your exercise ability

Membership Info

Membership Term *

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