Name *

First Name

Last Name

Phone *

(###)

###

####

Phone *

Emergency Contact Phone

(###)

###

####

*

Has your medical practioner ever told you that you have a heart condition or have you ever suffered a stroke?

Yes

No

*

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

Yes

No

*

Do you ever feel faint, dizzy or lose balance during physical activity/exercise?

Yes

No

*

Have you ever had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Yes

No

If you have diabetes (type 1 or type 2) have you had any issues controlling your blood sugar (glucose) in the last 3 months?

Yes

No

*

Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?

Yes

No