Birth date *

Gender * Female Male

Height (eg 165 cm) & Weight (eg 65 kg)

Emergency Contact Name & Number

Relation to You

Primary Care Physician Name & Phone Number

How did you hear about Defy? * Heard from friend Searched online Got an email about us Facebook Pass by

Medical Questionnaire

Are you currently pregnant? Yes No

Please list any medical conditions you are currently being treated for.

Do you currently have or have you ever had? (check all that apply) High Blood Pressure Low Blood Pressure Any Heart Disorder/Disease Flutters or Arrhythmias Any Valve Disease Coronary Disease/Heart Vessel Disease Any Heart Surgery Heart Attack (in the last 6 months) Pacemaker Peripheral Artery Occlusive Disorder Raynauds Disease Vasculitis COPD Active Shortness of Breath Asthma Bleeding Tendency Severe Anemia Loss of Consciousness Seizures/Epilepsy Bacterial or Viral Infection of the Skin Scleroderma Kidney or Urinary Tract Infection Cancer Hypothyroidism or Hashimotos Hyperthyroidism or Graves Diabetes Claustrophobia None

Do you have weak/lack of sensation in extremities? Yes No

Do you have any wounds? Yes No

Any other disorder or illness not listed above? (please explain)

What is your biggest health concern at this time?

Do you currently feel healthy? Yes No

If you could improve one thing about your health, what would it be?

Safety Instructions and Waiver of Liability * No I understand the safety instructions provided and I also agree that I do not have any of the contraindications listed and I understand and accept the possible risks of Cryotherapy and Floatation. And I voluntarily agree to each term and provision herein and sign this of my own will.