Please Fill Out Health History Form and Hit Submit 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 Emergency Contact Name * Emergency Contact Phone * What is your age? * 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 * Clear Your handwritten signature here. Submit If you are human, leave this field blank.
