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