Have you had any family history of chronic disease (heart disease, diabetes, etc.)
Have you ever been diagnosed or treated for any chronic disease including asthma?
Are you currently taking any medication?
Any other conditions that we need to be aware of (i.e. Past or present injuries, etc)?
Do you smoke?
Do you drink alcohol regularly?
Please rate the following. One star meaning you do not agree, five stars meaning you fully agree.
Do you have any health related goals (i.e. Lower blood pressure, etc)?
Do you have specific goals related to body composition (i.e. weight loss, build biceps etc)?
Do you have any performance specific goals (i.e. Increase 10km run, increase chest strength, etc.)?
Do you wish to achieve any of these goals in a specific time frame?
Please read carefully before submitting form.
I agree, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with The MBS Connection .
Having such knowledge, I hereby release The MBS Connection, their representatives, agents, and successors from liability for accidental injury or illness, which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.
I agree to disclose any physical limitations, disabilities, ailments, or impairments that may affect my ability to participate in said fitness program.
