Submit Health History

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Health History Form

Full Name *

Email *

Confirm Email *

Address *

Address

Address

Address

City

City

State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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

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