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Medical Clearance

Please complete this form within the 4 weeks before the start of the challenge

Participant Information
1. Has the participant already joined a team? *This question is required.
This question requires a valid date format of DD/MM/YYYY.
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This question requires a valid number format.
This question requires a valid email address.
For health professional to complete
7. Has the participant had 715 health check in the past 12 months?

A 715 health check should be completed within 6 months of starting the challenge *This question is required.
8. Please indicate if the participant has experienced a cardiac event or asthma attack requiring immediate medical attention in last 12 months. *This question is required.
9. Please indicate if the participant has unstable or untreated heart or circulatory disease. *This question is required.
10. Please indicate if the participant has a history of undiagnosed chest pain. *This question is required.
11. Please indicate if the participant has a history of unexplained faintness. *This question is required.
12. Please indicate if the participant has a history of unexplained shortness of breath. *This question is required.
13. Please indicate if the participant is post-surgery under 3 months (including but not limited to cardiac surgery, joint replacement, wound healing). *This question is required.
14. Please indicate if the participant is pregnant. *This question is required.
16. If answer is 'Yes' to any of the questions above, or if the participant has any other medical conditions which require monitoring, a doctor must assess fitness to participate in the challenge.

Please indicate: *This question is required.
This question requires a valid number format.
25. For health professional: Please sign the box below  *This question is required.
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