Health Waiver

First Name *

Last Name *

Phone *

Email *

Date of birth *

Gender *

Male
Female
Non Binary
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Occupation *

Do you have a doctor’s permission to participate in physical activities? *

Yes

No

When was your last visit with your primary care doctor? *

Phone Number of primary care doctor:

Has your doctor ever said that you have a heart condition or high blood pressure? *

Yes

No

Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity? *

Yes to any or all

No to none

Any food allergies? If so please list them: *

Do you lose balance because of dizziness or have you ever lost consciousness in the last 12 months? *

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 *

Yes

No

Do you smoke cigarettes? *

Yes

No

How many times do you smoke in week? *

0 times

1-2 times

3-5 times

6 or more times

If you quit, when did you stop?

Do you drink alcohol? *

Yes

No

How many drinks do you have in week? *

0

1-2 Drinks

3-5 Drinks

6 or more Drinks

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Signature *

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