Submit Health History

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Health History Form

Full Name *

Email *

Confirm Email *

Address *

Address

Address

Address

City

City

State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

State/Province

Zip/Postal

Zip/Postal

Your Phone *

Tell Us About Your Yourself *

Male

Female

Are You signing for a minor

Yes

No

If signing for a minor state relationship

State minor name

State minor age

What is your age? *

Emergency Contact Name *

Emergency Contact Phone *

Heart problems chest pain or stroke *

YES

NO

Increased blood pressure *

YES

NO

Any chronic illness or condition *

YES

NO

Difficulty with physical exercise *

YES

NO

Recent surgery last 12 months *

YES

NO

Pregnancy now or past 6 months *

YES

NO

Breathing or lung problems *

YES

NO

Muscle joint or back disorders *

YES

NO

Any pain or discomfort not diagnosed as injury *

YES

NO

Diabetes or thyroid condition *

YES

NO

History of heart trouble in family *

YES

NO

Hernia now or in the past *

YES

NO

Cigarette smoking habit *

YES

NO

Alcohol consumption more than 3 drinks per week *

YES

NO

Back condition (herniated or ruptured disc) *

YES

NO

Heart attack *

YES

NO

Coronary bi pass or angioplasty *

YES

NO

Have you ever been hospitalized *

YES

NO

Knee problems *

YES

NO

Shoulder problems *

YES

NO

Arthritis Rheumatism *

YES

NO

Impaired circulation *

YES

NO

High blood cholesterol *

YES

NO

Describe present or past exercise program *

Comments regarding YES to answers above or anything significant to your present health:

Comments regarding YES to ANY SURGERIES OR BEING HOSPITALIZED:

Type Your Name To Validate This Form *

RESPONSIBILITY FOR ANY ILLNESS, ACCIDENT OR INJURY I MAY INCUR FROM THE USE OF THE PROGRAMS, SERVICES OR FACILITIES. ALL INDIVIDUALS ARE STRONGLY ENCOURAGED TO CONSULT WITH A PHYSICIAN BEFORE ENTERING A NON-MEDICALLY SUPERVISED EXERCISE PROGRAM: *

I AGREE

I DO NOT AGREE

Draw your Signature *

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