Medical Questionnaire and Training Agreement
Fitness Medical Health and Demographic Questionnaire
First Name *
Last Name *
Age *
Date of Birth *
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Street Address *
City *
State/Province/Region *
Zip/Postal Code *
Phone Number *
Country *
Email Address *
T-Shirt Size *
Physician's Name *
Physician's Phone Number *
Emergency Contact Name *
Emergency Contact Phone Number *
Do you now, or have you had in the past: *
Yes
No
History of heart problems, chest pain, or stroke
Increased blood pressure
Recent surgery (past 12 months)
Pregnancy (current or within past 3 months)
History of breathing or lung problems
Muscle, joint, back disorder, or any previous injury still affecting you
Diabetes or thyroid condition
Hernia, or any condition that may be aggravated by lifting weights
Any chronic illness or condition
Are you taking any medications or drugs?
Do you suffer from dizziness or loss of consciousness?
Cigarette smoking habit
Increased cholesterol
History of heart problems in immediate family
If you answered yes to any of the above questions, please explain below. Include any other information that you feel is pertinent to this questionnaire.
Informed Consent and Training Agreement
Full Name as Digital Signature *
Date *
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By checking this box, you are digitally certifying that all information on this form is correct to the best of your knowledge. *
Required
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