Pre-Exercise Health Screening
Please complete this form to help us understand your health status before starting an exercise program.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any known heart conditions?
*
Yes
No
Do you experience chest pain during physical activity?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have any joint or bone problems that could be aggravated by exercise?
*
Yes
No
Are you currently taking any medications?
*
Yes
No
Please list any other medical conditions or concerns:
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: