Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Please check any that apply:

You have had unexplained chest pain

Have a family history of heart disease or stroke?

You have a heart condition or have suffered a stroke

Have blood pressure over 130/90 (for either the top or bottom number)?

You experience imbalance or dizziness when exercising

You have had an asthma attack that required medical attention in the last 12 months

Do you smoke? (Or recently quit?)

Diabetics: you have had trouble controlling your blood sugar over the last 6 months

Sit down most of the day, most days?

Have you been pregnant/given birth? (If yes, please provide details below)

Medical conditions that I should know about / that affect your training?

None of the above