Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Do you now or have you had any of the following in the past? *

Please check all that apply.

History of heart problems, chest pain or stroke

Elevated blood pressure

Low blood pressure

Any chronic illness or condition

Difficulty with physical exercise

Advice from a physician not to exercise

Recent surgery in the last 12 months

Pregnancy now or within the last 3 months

History of breathing or lung problems

Muscle or joint injuries or issues

Previous soft tissue injuries

Diabetes or metabolic syndrome

Thyroid condition

Cigarette smoking habit

Obesity

Elevated blood cholesterol

History of heart problems in immediate family

Hernia or any condition that might be aggravated by lifting weights

Significant vision or hearing problems

Do you smoke cigarettes?

None of these apply to me.