My account

First Name *

Last Name *

City *

Phone *

Date of Birth *

Gender * Male Female

Do you have any chronic disease? * Yes No

Has your doctor ever said you have a heart condition & that you should only do physical activity recommended by a doctor? * Yes No

Do you feel pain in your chest when you do physical activity? * Yes No

In the past month, have you had a chest pain when you were not doing physical activity? * Yes No

Do you lose balance because of dizziness or do you ever lose consciousness? * Yes No

Do you have a bone or joint problem (ex: back, knee or hip) that could be made worse by a change in your physical activity? * Yes No

Is your doctor currently prescribing medication for your blood pressure or heart condition? * Yes No

Do you know of any other reason why you should not take part in physical activity? If YES, please comment: *

I have carefully read this Agreement and fully understand its contents. I am aware that this is a release & waiver of liability & sign it knowingly, voluntarily, & of my own free will *