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FitLabPGH Medical History & Waiver
Please type your email address (required) and then complete the form and waiver below the red labrador. Don't forget to click on the "submit" button after signing and dating the waiver
Email address *
Name
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Date of Birth
MM
/
DD
/
YYYY
Address
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City
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State
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Zip code
Your answer
Home phone #
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Cell phone #
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In an emergency I would like FitLabpGH to call
Your answer
Please describe your current and/or previous exercise experience
Your answer
What are your primary health and fitness goals? (Check all that apply)
Do you have any allergies we should know about (drug, latex, other?
Your answer
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
If you answered "yes" to any of the above questions please explain
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Please mark all that apply
Please list all over the counter medications you are taking (including supplements)
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Please list all prescription drugs you are taking
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Please list all surgeries you have had in the past
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