PAY MONTHLY
COMPETITIVE BOXERS
BOXING
CIRCUITS
LADIES BOXING
U 16’s
U 11’s
U 8’s
MY BOOKINGS
Checkout
SHOP
Menu
PAY MONTHLY
COMPETITIVE BOXERS
BOXING
CIRCUITS
LADIES BOXING
U 16’s
U 11’s
U 8’s
MY BOOKINGS
Checkout
SHOP
PAY MONTHLY
COMPETITIVE BOXERS
BOXING
CIRCUITS
LADIES BOXING
U 16’s
U 11’s
U 8’s
MY BOOKINGS
Checkout
SHOP
Menu
PAY MONTHLY
COMPETITIVE BOXERS
BOXING
CIRCUITS
LADIES BOXING
U 16’s
U 11’s
U 8’s
MY BOOKINGS
Checkout
SHOP
Medical form submission
Name
Age
Weight
Emergency Contact Name
Emergency Contact Number
Emergency Contact Relationship
Do you take any regular medication?
NO
YES
If YES - please explain.
Do you smoke?
NO
YES
Are you pregnant?
NO
YES
Do you drink alcohol more than three times per week?
NO
YES
Do you have high stress levels?
NO
YES
Are you moderately active on most days of the week?
NO
YES
Do you have or have ever had
High Blood Pressure?
NO
YES
High Cholesterol?
NO
YES
Diabetes?
NO
YES
A Heart Attack?
NO
YES
Heart Disease?
NO
YES
A Heart Murmur?
NO
YES
Chest Pain With Exertion?
NO
YES
Irregular Heart Beat or Palpitations?
NO
YES
Light-Headedness or Fainting?
NO
YES
Unusual Shortness of Breath?
NO
YES
Cramping Pains in Legs or Feet?
NO
YES
Emphysema?
NO
YES
Other Metabolic Disorders (e.g. Thyroid, Kidney etc)
NO
YES
Epilepsy?
NO
YES
Asthma?
NO
YES
Back Pain - Upper, Middle, Lower?
NO
YES
Any Other Joint Pain?
NO
YES
Muscle Pain?
NO
YES
If you have answered yes to any of the above please explain below:
Do any of your family members have a history with, or suffer from any of the above?
Do you have any pre-existing boxing injuries?
Date
I accept
I certify that the information I have provided is to the best of my knowledge, factual, accurate and up to date. I also acknowledge that it is my responsibility to update The School of Hard Knox with an up to date medical form should there be any changes to my health that would result in different answers to the ones provided in this form submission, and that by ticking this box I am signing as either the person named at the start of this form or as a parent or guardian with the authority to do so on the attendees behalf.
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