Forms - Women Warriors Waiver and Fitness Forms

Name *

First

Last

Email *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Next Of Kin (ICE) *

First

Last

Next Of Kin Contact Number (ICE) *

Have you Experienced any of the Following? Pain or discomfort (or anginal equivalent) in the chest, neck, jaw, arms, or other areas that may be due to ischemia (decreased blood flow) *

Yes
No

Shortness of Breath at rest or mild exertion? *

Yes
No

Dizziness of syncope at rest or mild exertion? *

Yes
No

Orthopnea/paroxysmal nocturnal dyspnea (shortness of breath) at rest or mild exertion *

Yes
No

Edema (excessive accumulation of tissue fluid) *

Yes
No

Palpitations or tachycardia (sudden rapid heart beat) *

Yes
No

Intermittent claudication (lameness due to decreased blood flow) *

Yes
No

Known heart murmur (abnormal heart sound) *

Yes
No

Do you smoke? *

Yes
No
Occasionally

Do you drink? *

Yes
No
Occasionally

Have you been a member of a health club before? *

Yes
No

Have you been exercising regularly for the past 6 months? *

Yes
No

Please rate your exercise level on a scale of 1-5 (5 indicating very strenuous) for each age range through to your present age: 15-20 *

Are you currently involved in regular endurance (cardiovascular) exercise? *

Yes
No

If yes, please specify the type of exercise(s)

And how many days per week?

Number of minutes per day?

Please answer the following: "I would like to..." *

On a scale of 1-5, with 5 being very serious, how serious are you about achieving your goals? *

Is there anything else your trainer should be aware of?

Fitness Assessment Form

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