Peak Performance Personal Training Application and Waiver
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Name
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Cell Phone
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Date of Birth
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Emergency Contact
First, Last and Relationship
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Medical Information
Approximate Date of Last Physical
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Physician Name
Type "No" if do not have
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Are you Currently under a doctor's care
If Yes to above, Explain
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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:
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Have you been recently hospitalized?
If Yes, please explain:
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Do you smoke?
Are you pregnant?
Do you drink alcohol more than three times/week?
What is your Daily Stress Level?
The Dude
Piglet
Do You have now, or have you had within the past year:
What regular physical activity do you presently?
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