Date
Health History Questionnaire and Consent Waiver
Name
DOB
Street address
City/State/Zip
Phone (1)
Phone (2)
Email
Gender
Emergency Contact and Phone
How did you hear about me?
Which Camp are you signing up for?
Please answer all the following questions to the best of your ability and knowledge
Section 1
Have you ever had any of the following?
Heart attack or heart failure?
Heart Surgery?
Metabolic diseases?
A pacemaker or other heart device?
A heart valve or congenital heart disease?
Pulmonary disease?
A Stroke
Coronary Artery Disease?
If you are a woman, are you pregnant?
Musculoskeletal or nerve problems?
Section 2
Have you ever experienced any of the following?
Pain in your chest, neck or jaw?
Shortness of breath with mild exertion?
Palpitations, tachycardia, or irregular heart beat?
Orthopnea or Paroxsomal Nocturnal Dyspnea
Intermittent claudication or thrombosis?
Ankle swelling?
Heart murmur?
Dizziness?
Section 3
Indicate if you have had any of the following or if any apply to you:
You are a male older than 45 years of age.
You are woman over 55 years of age or have had a hysterectomy or are postmenopausal.
You smoke or have quit smoking in the last 6 months.
You have blood pressure greater than 140/90.
You are physically inactive or get less than 30 minutes of physical activity on at lest 3 day per week.
You have total cholesterol greater than 200 mg/dL.
A close male relative who had a heart attack before age 55 or a close female relative who had a heart attack before age 65.
You have diabetes or take medication to control blood sugar.
Take prescription medication.
You are more than 20 pounds overweight.
Informed Consent
The exercise sessions you will become involved with and undertake will consist of progressive exercise levels and be determined and regulated by your trainer. The exercise sessions will consist of aerobic and weight training as well as education and instruction. These exercises are designed to place a gradual increasing stress on the body and as such to improve the body’s function, although no guarantee can be made.
Initials
I am aware that all activities are offered as recreational or self directed in nature and I have the right and choice to stop activity at any time. I also assume full responsibility during and after my participation for any risk, discomfort or fatigue that I may experience. I understand that exercise and cardiovascular activity and the response of my body to such activity cannot be predicted. I acknowledge my responsibility and obligation to inform the nearest supervising employee of any pain, discomfort, fatigue or any other symptoms that I may suffer and that it is my choice to participate in the training program. I also understand that my trainer or other staff may not be licensed, certified, or registered instructor and that skill levels may vary and that I accept assumption of all the risk that may imply as my own.
Initials
The information made and obtained during the training sessions is treated as confidential. However it may be used for statistical purpose as long as my privacy is not compromised.
Initials
I understand that I may ask any questions or request further information about any of the activities, programs, or services offered at any time before, during or after participation. I may take as long as I need to think the program over and can participate now or withdraw at any time.
Initials
I have read and agree with the above and consent to participate in private/group exercise training.
Intials
I certify that all of the above are answered truthfully to the best of my knowledge, and I accept the risk involved with any non-disclosures whether intentional or otherwise.
Initials
After Submitting, you will be taken to the online store where you can submit payment if you wish. Payment can also be made in person prior to the start of camp.
