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First Name
Email
Phone Number
Last Name
Date of Birth
Emergency Contact
1) Do you frequently have pains in your chest when you perform physical activity?
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2) Have you had chest pain when you were not doing physical activity?
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3) Do you lose your balance due to dizziness or do you ever lose consciousness?
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4) Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?
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5) Are you pregnant now or have given birth within the last 6 months?
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6) Have you had a recent surgery?
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Please specify anything we should know about
I declare that the info I’ve provided is accurate & complete
I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.
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