Name *

First Name

Last Name

Phone *

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1. Have you experienced any past injuries or sustained illnesses that limit you from performing physically challenging activities? *

Yes

No

2. Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

3. Are you taking any prescribed medication at this time? *

Yes

No

4. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

5. (Females only) Are you pregnant? *

Yes

No