PHYSICAL QUESTIONNAIRE

Medical & Health Assessment

Personal

General Health

Combat Sports

Submit

Full Name *

ID / Passport *

Date of Birth *

Phone *

Email *

Emergency Contact *

Emergency Phone *

1. Has a doctor ever told you that you have a heart condition or should only exercise under medical supervision?

Yes No

2. Do you experience chest pain during physical activity?

Yes No

3. Have you experienced chest pain while resting in the last month?

Yes No

4. Do you suffer from dizziness, blackouts, or loss of balance?

Yes No

5. Are you currently on medication for blood pressure, heart conditions, or circulation issues?

Yes No

6. Have you ever been diagnosed with a concussion or traumatic brain injury?

Yes No

7. Do you experience frequent headaches, migraines, or blurred vision?

Yes No

8. Do you have any neck, spine, shoulder, elbow, wrist, hip, knee, or ankle injuries that could be aggravated by striking or grappling?

Yes No

9. Have you ever been advised by a medical professional not to participate in contact sports?

Yes No

10. Do you have a history of seizures, fainting, or neurological conditions?

Yes No

11. Do you have any condition that may affect your ability to safely participate in sparring or high-intensity training?

Yes No

12. Are you currently recovering from surgery or injury?

Yes No

If YES to any question, please provide details:

I confirm that the information provided is accurate. I acknowledge the risks of combat sports training and agree to follow all safety instructions.

I confirm the above information is true and complete

Today's Date

✅ Questionnaire submitted!