Peak Performance Personal Training Application and Waiver
First and Last
Date of Birth
First, Last and Relationship
Approximate Date of Last Physical
Type "No" if do not have
Are you Currently under a doctor's care
If Yes to above, Explain
Have you ever had an exercise stress test?
If Yes, were the results:
Do you take any medications on a regular basis?
If yes, please list medications and reasons for taking:
Have you been recently hospitalized?
If Yes, please explain:
Do you smoke?
Are you pregnant?
Do you drink alcohol more than three times/week?
What is your Daily Stress Level?
Do You have now, or have you had within the past year:
History of heart problems?
High blood pressure?
A heart attack?
History of Heart problems in immediate family?
Difficulty with physical exercise?
Chest pain with exertion?
Do you get Lightheaded or do you faint?
Unusual shortness of breath?
History of lung problems?
Muscle, joint or back disorders that could be aggravated by physical activity?
What regular physical activity do you presently?
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