Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever had any form of heart disease? *

Yes

No

Do you have a family history of heart disease? *

Yes

No

Do you have high blood pressure? *

Yes

No

Are you a smoker? *

Yes

No

Do you have any allergies? *

Yes

No

Are you currently taking any medications? *

Yes

No

Do you have any injuries or surgeries? *

Yes

No

Do you have diabetes? *

Yes

No

Do you suffer from Asthma? *

Yes

No

Do you have any back problems? *

Yes

No

Do you have any knee problems? *

Yes

No

Do you have any hip/pelvis problems? *

Yes

No

Do you have any shoulder/neck problems? *

Yes

No

Have you participated in strenuous exercise before? *

Yes

No

Are there any exercises you know you can't do? *

Yes

No

Are you currently exercising? *

Yes

No

Is there any reason why you shouldn't partake in exercise/any other health conditions not listed? *

Yes

No

Are you currently experiencing any of the following symptoms; fever, chills or sweats, cough, sore throat, shortness of breath, runny nose, lose of sense of smell? *

Yes

No

Are you currently required to be in isolation for a period of 7-days as a result of contracting COVID-19? *

Yes

No

By checking the box below you are agreeing to the above 'assessment of risk & waiver of liability', and this checked box will act as a formal signature agreement. *

I Agree