Health Waiver
First Name
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Last Name
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Phone
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Email
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Date of birth
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Gender
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Male
Female
Non Binary
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Occupation
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Do you have a doctor’s permission to participate in physical activities?
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Yes
No
When was your last visit with your primary care doctor?
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Phone Number of primary care doctor:
Has your doctor ever said that you have a heart condition or high blood pressure?
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Yes
No
Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?
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Yes to any or all
No to none
Any food allergies? If so please list them:
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Do you lose balance because of dizziness or have you ever lost consciousness in the last 12 months?
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Yes
No
Do you currently have or have had, (within the past 12 months) a bone, joint or soft tissue, muscle ligament or tendon problem that could be made worse by becoming more physically active
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Yes
No
Do you smoke cigarettes?
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Yes
No
How many times do you smoke in week?
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0 times
1-2 times
3-5 times
6 or more times
If you quit, when did you stop?
Do you drink alcohol?
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Yes
No
How many drinks do you have in week?
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0
1-2 Drinks
3-5 Drinks
6 or more Drinks
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Signature
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