Boot Camp Date
Location / Time
Full Name *
Address *
City *
State *
Zip Code *
Phone *
E-Mail *
Date of Birth *
Preferred Contact
  Does your physician approve of your participation in this exercise program?

Yes    No

  Are you taking any medications that affect your vital signs (heart rate, blood pressure, breathing, etc.) or physical performance?

Yes    No

  Do you now or have you had in the past?
(Check all that apply)

History of heart problems in the immediate family
Cigarette, cigar, or pipe smoking habit
Increased blood pressure
Increased total blood cholesterol (>200 mg/dL)
Diabetes mellitus
History of heart problems, chest pain, or stroke
History of breathing or lung problems
Muscle, joint, or back disorder
Previous injury still affecting you
Any condition aggravated by lifting weights?
Any chronic illness or condition
Obesity (more than 20% over ideal body weight)
Recent surgery (last 12 months)
Pregnancy (now or within last year)
Difficulty with physical exercise
Advice from physician not to exercise

  Rate your current fitness level from 1-10.
(10 being the fittest)

  How did you hear about Fitness411 Boot Camp?




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