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Registration

Please fill in your name and contact information & select days you will be coming.

Monday

Wednesday

Friday

First Name:*

Last Name:*

Email Address:*

Address:*

City:*

Zip Code:*

Phone*

Date of Birth*

Health Assessment

Date of last full physical?*

Have you ever had any form of heart disease?

Have you ever experienced shortness of breath or chest pains?

Do you have or do any of the following pertain to your health? If yes please explain. If not please type N/A

High blood pressure? Levels*

Do you smoke cigarettes pipe or use tobacco products?*

Diabetes? Type*

Family history of heart disease? Who and age?*

Do you work out regularly? How often*

What are your goals in starting class?*

Are you currently taking any medication or herbal suppliment? Explain*

Do you have problems in the following areas?

Knees

Lower Back

Hip/Pelvis

Other

Please explain.*

How did you hear about the class?

If other please describe.*

Comment

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