Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Has your doctor ever said that you have/had a heart condition and that you should only do physical activity under medical supervision? *

Yes

No

Do you ever feel pain in your chest with exertion, or had chest pain in the last six months? *

Yes

No

Do you experience severe dizziness, fainting or blackouts? *

Yes

No

Do you have asthma, epilepsy , diabetes type | or II? *

Yes

No

Do you have high/low blood pressure? *

Yes

No

Do you have any issues with your joints, muscles or bones? *

Yes

No

Have you had surgery for any reason? *

Yes

No

Have you had surgery for any reason? *

Yes

No

Are you pregnant? If yes, at what stage?

No

Yes - 1st Stage

Yes - 2nd Stage

Yes 3rd Stage

Have you given birth in the past six months? *

Yes

No

Do you know of any other reason why you should not do physical activity? *

Yes

No