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Fitness Equipments

QUICKWORKS MEDICAL EXERCISE

"Getting You Back To Function As Quickly And Safely As Possible"

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Medical Questionnaire

Please fill out the following form to help us understand your physical condition. Any information shared with QuickWorks Medical Exercise LLC will not be sold to any third parties.

First Name

Last Name

Email Address

Have you been hospitalized in the last 12 months? *

No

Yes

Are you currently suffering from a medical condition, illness, or injury? *

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Medical Questionnaire

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Health declaration

Please fill out the following form.

First name

Last name

Email*

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Initials*

I declare that the info I’ve provided is accurate and complete.

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