Name *

First Name

Last Name

Today's Date

MM

DD

YYYY

Date of Birth

MM

DD

YYYY

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Has a doctor ever said that you have a heart condition? *

Yes

No

Have you ever had high blood pressure? *

Yes

No

Do you have any metabolic diseases, controlled or uncontrolled, such as diabetes, hyperthyroidism, hypothyroidism, etc.? *

Yes

No

Have you ever had a seizure, been diagnosed with epilepsy or another neurological disorder? *

Yes

No

Do you have a bone or joint problem that could be aggravated by the proposed physical activity? *

Yes

No

Are there any other physical, medical or emotional problems that may affect your training? Or that you think I should know about?? *

Yes

No

Have you ever had an injury that caused you to stop exercising for more than 1 week? *

Yes

No

Are you aware, through your own experience or a doctor’s advice, of any other physical reasons against your exercising without medical supervision? *

Yes

No

Do you prefer Monday or Tues nights best for our monthly meeting? *

Monday

Tuesday

Either