Weight Training Health Screening
Please complete this form to help us assess your readiness and safety for weight training activities.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have, or have you ever had, any of the following conditions?
*
Heart disease or chest pain
High blood pressure
Diabetes
Asthma or respiratory problems
Joint or bone problems
Recent surgery (last 12 months)
None of the above
Other (please specify)
Are you currently taking any medication? If yes, please list them.
*
Do you have any current injuries or physical limitations?
*
No
Yes (please describe below)
If yes, please describe your injury or limitation.
How would you rate your current physical activity level?
*
Sedentary (little or no exercise)
Lightly active (light exercise/sports 1-3 days/week)
Moderately active (moderate exercise/sports 3-5 days/week)
Very active (hard exercise/sports 6-7 days/week)
What are your primary goals with weight training?
*
Increase strength
Build muscle
Lose weight
Improve general health
Sports performance
Other (please specify)
Please list any other relevant health information or concerns.
Signature
*
Submit
Submit
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