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Health Waiver

First Name

Last Name

Age

Gender

Phone

Occupation

Do you have a doctor’s permission to participate in physical activities?

Yes

When was your last visit with your primary care doctor?

Phone Number of primary care doctor:

Has your doctor ever said that you have a heart condition or high blood pressure?

Yes

Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?

Yes to any or all

No to none

Any Food Allergies?

Yes

Allergies

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?

Yes

Do you currently have or have had, (within the past 12 months) a bone, joint or soft tissue, muscle ligament or tendon problem that could be made worse by becoming more physically active

Yes

Has your doctor ever said that you should only do medically supervised physical activity?

Yes

Do you smoke?

Yes

How many years did you smoke?

If you quit, when did you stop?

Do you drink alcohol?

Yes

How often do you drink?

1-3 drinks weekly

3-6 drinks weekly

6-9 drinks weekly

I have read and agree to the Terms and Conditions and Privacy Policy

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‪(202) 743-0662‬
support@miniontraining.com

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How Can Stiff and Tight Muscles Result in Back Pain

February 1, 2023 No Comments

Dominion Ezechibueze — miniontraining.com Jan 31, 2023 Back pain is a common ailment that affects many people at some point in their lives. While there

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How Can Stiff and Tight Muscles Result in Back Pain

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