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NBM Fitness Questionnaire
Natural Body Man's Fitness Questionnaire. Fill one out today!
First Name:
*
Last Name:
*
Home Address:
City:
State:
Zipcode:
Home Phone:
*
Cell Phone:
Email Address:
*
Age:
DOB:
Sex:
select...
M
F
Height:
Weight:
Physician's Name:
Physician's Number:
Emergency Contact:
Emergency Contact #:
Heart attack, coronary bypass or other coronary surgery? :
*
Y
N
Chest discomfort (especially with exertion)? :
*
Y
N
High blood pressure? :
*
Y
N
Extra, skipped or rapid heart beats/palpitations? :
*
Y
N
Heart murmurs, clicks, or unusual cardiac findings? :
*
Y
N
Rheumatic fever? :
*
Y
N
Ankle swelling? :
*
Y
N
Peripheral vascular disease? :
*
Y
N
Phlebitis, emboli? :
*
Y
N
Unusual shortness of breath? :
*
Y
N
Light headedness or fainting? :
*
Y
N
Pulmonary disease (e.g., asthma, emphysema and bronchitis)? :
*
Y
N
Abnormal blood lipids (cholesterol, triglycerides)? :
*
Y
N
Stroke? :
*
Y
N
Recent illness, hospitalization or surgical procedure within the past four months?:
*
Y
N
Medications of any kind? (if yes, list all below) :
*
Y
N
Diabetes or other metabolic disorders? :
*
Y
N
Are you pregnant now? :
*
Y
N
Is there any reason your physician would object to your dieting? :
*
Y
N
Is there a history of heart disease in your family? :
*
Y
N
Is there any reason your physician would object to your exercising? :
*
Y
N
Please list any other medical issues we should know about.:
** All client information is kept strictly confidential and never shared with anyone for any reason.**
** WAIVER / RELEASE **
I, the undersigned, have read, understand, and have answered the above health/medical survey questions fully and truthfully. I have consulted with my personal physician regarding my medical fitness to engage in strenuous exercise and nutritional support program. I am legally bound for myself and waive release of any and all rights and claims for damages as a client of Christopher Carr and Broward County Parks and Recreation Division for any and all injuries and negligence suffered while following the fitness training and/or nutrition program provided to me. In addition, I consent to any photography and DVD/Video broadcasting of myself, while attending The FunWorkout via mass media, internet, DVD or other media not indicated.
Client Name :
*
Client Agreement Checkbox:
*
select...
Yes. I agree to the above information.
Client Signature:
(this can be signed at your first class)
