Name: _________________________________ Date: _______________

Address: _______________________________ Age: ____ DOB: _____

City: _________________________ State: ___ Sex: __ Weight: _____

Zip: _____________________ E-mail: ___________________________

Home #: ___________ Business #: ___________ Cell #: __________

Emergency contact: _______________ Phone #: _________________

Physician name: __________________ Phone #: __________________

Address: ____________________________________________________

Date and reason last consulted: ________________________________

• Has your physician ever advised you against exercising?

  Yes □ No □

  If yes, please explain: _____________________________________

  _________________________________________________________

• Do you know or have you ever experienced any of the following:

• Do you have or did a physician ever diagnose you as having any of the following:

  ____________________________________________________________

• Are you presently under a physician's care for any of the above, or any other condition?

  Yes □ No □

  If yes, please explain. _____________________________________

  _________________________________________________________

• Have you had any major illnesses and/or surgeries?

  Yes □ No □

  If yes, please explain. _____________________________________

  _________________________________________________________

• Do you have any current medical problems or incompletely healed injuries?

  Yes □ No □

  If yes, please explain. _____________________________________

  _________________________________________________________

• Have you had or do you now have any bone, joint (including spine), or muscle injuries or diseases?

  Yes □ No □

  If yes, please explain. _____________________________________

  _________________________________________________________

• Are you presently receiving physical therapy?

  Yes □ No □

  If yes, please explain. _____________________________________

  _________________________________________________________

• Is there any position, activity, exercise, or task that causes you concern or pain?

  Yes □ No □

  If yes, please explain. _____________________________________

  _________________________________________________________

• In what way do your symptoms interfere with your daily activities?

  _________________________________________________________

  _________________________________________________________

• If you do experience any pain or discomfort, what causes the symptoms?

  _________________________________________________________

  _________________________________________________________

• Are you presently taking medications? Please list dosage and reason.

  _________________________________________________________

  _________________________________________________________

Providing your signature will indicate that all of the information provided above is true to the best of your knowledge. That ____________________ Company name ____________________ will be notified if and when there are any physical or mental conditions that may affect physical activity.

Name: ________________________ Sign: _________________________

Date: ____________________