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.