First Name

Last Name

Email Address

Phone Number

Address

Gender

Birth Date

Emergency Contact Info

Has the athlete whom this form applies to ever been diagnosed with a heart condition?

Has the athlete whom this form applies for ever been diagnosed with Diabetes (Type I or II)?

Has the athlete whom this form applies to ever been diagnosed with high blood pressure?

Has the athlete whom this form applies ever experienced chest pain when working out?

Has the athlete whom this form applies to ever had chest pain outside of exercising?

Has the athlete whom this form applies have any issues with balance or light headedness?

Does the athlete whom this form applies have any bone/joint disease that interferes with exercise?

Is that athlete whom this form applies taking any medication that alter heart rate/blood pressure?

Does the athlete whom this form applies to currently/recently quit tobacco?

How often does the athlete whom this form applies currently exercise? (days/week, type)