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 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 Draw your Signature * signature keyboard Clear Your handwritten signature here. CAPTCHA If you are human, leave this field blank. Submit
