Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Sex at Birth

Male

Female

Prefer not to say

What services are you interested in? *

Personal Training

Massage

Heart Condition *

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

Yes

No

Chest Pain *

Do you feel pain in your chest when you perform physical activity?

Yes

No

Chest Pain at Rest *

In the past month, have you had chest pain when you were not performing any physical activity?

Yes

No

Dizziness or Loss of Consciousness *

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

Yes

No

Bone or Joint Problems *

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes

No

Blood Pressure or Heart Medications *

Is your doctor currently prescribing any medication for your blood pressure or a heart condition?

Yes

Yes