The Health Escape Booking

THE HEALTH ESCAPE REGISTRATION

- Recharge, Restore, Revitalise on the South Coast of KwaZulu Natal!
PERSONAL INFORMATION
Full Name

First NameLast Name
Sex
Birth Date

MonthDayYear
Which city do you live in?
Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
E-mail
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
How fit are you (1=not at all; 5=very)
What is your purpose for coming to The Health Escape?
How did you hear about The Health Escape?
BOOKING DETAILS
Please select the date you would like to attend
Would you like a single / double room?
If you selected a double room, who are you sharing with & would you like a king bed or twin beds?
Do you have any special dietary requirements?
Do you have any other special requirements?
Are you driving to Munster or flying to Durban?
If you are flying to Durban, will you be renting a car or taking the Margate Shuttle to Munster?
If flying to Durban, please arrange with The Margate Shuttle for transport from King Shaka's International Airport to The Merry Crab Beach Resort in Munster or book a rental car. The Margate Shuttle: http://www.margate.co.za/minicoach.html. The Merry Crab Beach Resort: www.themerrycrab.co.za
MEDICAL QUESTIONS

If you answer YES to any of these, please give us as much additional info as possible.
Have you had an inactive lifestyle for 2 or more years?
Are you currently pregnant?
Are you a cigarette smoker? If so, how many cigarettes do you smoke per day?
Do you have diabetes? If so, what kind?
Do you suffer from high blood pressure (hypertension)?
Do you have high cholesterol?
Have you ever had a heart attack or been diagnosed with a heart condition?
Do you currently have a heart condition and have been advised not to participate in physical exercise?
Are you currently taking medication for a heart condition?
Do you have a heart murmur?
Do you have a family history of sudden cardiac death in an immediate family member who was under the age of 55 (male) or 65 (female)?
Do you ever experience feelings of faintness, severe dizziness, excessive breathlessness, or have you blacked-out after mild exertion?
Have you ever had pain or pressure in the left or mid-chest area, left neck, shoulder or arm, particularly during or shortly after exercise?
Have you had any surgery in the past 3 months?
Do you have any other prescribed medication not already mentioned on a permanent/semi-permanent basis?
Do you have any known allergies?
Have you ever had a back or neck injury?
Have you had knee pain the past 2 years that has disabled you for longer than a week?
Have you had a broken bone or fracture in the past 2 years?
Do you suffer from arthritis?
Do you suffer from seizures/epilepsy?
Do you have asthma?
Have you ever had deep vein thrombosis or pulmonary embolis?
Do you suffer from a lung disease?
Do you suffer from a kidney disease?
Do you suffer from a liver disease?
Do you have a low blood count (anaemia)?
Do you have raised blood sugar?
Any other medical or physical reasons why you should not partake in physical activity?
Should be Empty:

THE HEALTH ESCAPE REGISTRATION

PERSONAL INFORMATION

BOOKING DETAILS

MEDICAL QUESTIONS