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Steele Wellness
HEALTH & WELLNESS COACHING
Login / Join
Health Declaration
Please fill out the following form
in order to participate in our activity.
First Name
Last Name
Email
Date of Birth
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 question, please elaborate
Initials
I declare that the info I’ve provided is accurate & complete
Submit
Thanks for submitting!
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