Waiver & HHQ - Client Form

Client Name*

First Last

Client Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you ever had any form of heart disease?*

Have you ever experienced shortness of breath or chest pains?*

Date Of Last Full Physical Examination*

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

Do you feel pain in your chest when you do physical activity?*

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?*

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*

Do you know of any other reason why you should not do physical activity?*

Please Explain*

Do you have any or do any of the following pertain to your health? If yes, explain.

High blood pressure?*

Levels?*

Cigarette smoking?*

Diabetes?*

Type?*

Family history of diabetes?*

Who? What's Their Age?*

Do you exercise at least three times per week?*

Are you currently taking any medication?*

Please Explain*