Home 5 Services 5 Fitness Center 5 Membership Form Fitness Membership Application First Name Last Name Date of Birth Weight Height Address City State Zip Phone Number Email Work Phone Employeer and Occupation Emergency Contact Name Emergency Contact Number Emergency Contact Relationship Physician Are you currently taking prescribed medications for a chronic medical condition Are you currently taking prescribed medications for a chronic medical condition Yes No If you chose yes to taking prescribed medications for a chronic medical condition, please list those here. Do you have any mental health issues or learning difficulties that may impact your fitness goals or abilities? Do you have any mental health issues or learning difficulties that may impact your fitness goals or abilities? Yes No Do you have Arthritis, Osteoporosis, or back problems? Do you have Arthritis, Osteoporosis, or back problems? Yes No Do you have high blood pressure? Do you have high blood pressure? Yes No Has your doctor ever said that you have a heart condition? Has your doctor ever said that you have a heart condition? Yes No Do you feel pain in your chest at rest during daily activity or during physical activity? Do you feel pain in your chest at rest during daily activity or during physical activity? Yes No Do you lose balance because of dizziness or have you lost consciousness in the past 12 months? Do you lose balance because of dizziness or have you lost consciousness in the past 12 months? Yes No Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? Yes No Do you currently have a bone, joint, or soft tissue problem that may be made worse with exercise? Do you currently have a bone, joint, or soft tissue problem that may be made worse with exercise? Yes No Has your doctor ever said that you should only do medical-supervised activity? Has your doctor ever said that you should only do medical-supervised activity? Yes No Do you have respiratory disease? (This includes COPD, asthma, and pulmonary hypertension) Do you have respiratory disease? (This includes COPD, asthma, and pulmonary hypertension) Yes No Do you have a spinal cord injury? (This includes tetraplegia and Paraplegia) Do you have a spinal cord injury? (This includes tetraplegia and Paraplegia) Yes No Have you had a stroke? Have you had a stroke? Yes No Do you currently have cancer? Do you currently have cancer? Yes No Do you have any metabolic conditions? (This includes Type I, Type II, or pre-diabetes) Do you have any metabolic conditions? (This includes Type I, Type II, or pre-diabetes) Yes No Submit Application