First Name

Last Name

Email Address

Phone Number

Address

Company

Gender

Birth Date

Emergency Contact Name:

Emergency Contact Phone:

Have you been diagnosed with a heart condition?

If yes, please explain; if no, please say "N/A"

Should you only do activity recommended by a Dr?

If yes, please explain; if no, please say "N/A"

Have you had any chest pain in the past month?

Do you lose your balance because of dizziness?

Do you have a bone/joint problem? Ex. neck/hip

If yes, please explain; if no, please say "N/A"

Do you ever lose consciousness?

If yes, could it get worse with physical activity?

Are you taking any bp/cholesterol medication?

If yes, please list/explain medications.

Are there any reasons you should not be active?

If yes, please explain reasons.