Rank and File Fitness - Personal Training and Bootcamps

HEALTH ASSESSMENT FORM

By completing this form, I accept complete and full responsibility for my use of all apparatus, appliances, facility, privilege, and/or services whatsoever, owned and operated by and with Rank and File Fitness. In addition, I shall hold this company, its directors, officers, representatives, agents and shareholders harmless from any and all loss, injury, claim, damage, or liabilty sustained or incurred by me resulting therefrom.

*First Name
*Last Name
*Address
*City
*Zip Code
*Day Phone
*Evening Phone
Email Address
*Sex	Male Female
*Age
*Height
*Weight
*Rate Your Current Fitness Level
How did you hear about Rank and File Fitness?
*Emergency Name and Contact Phone Number
*Date of Last Physical Exam or Doctor's Visit:
*Do you have high blood pressure?	Yes No
*Do You have high cholesterol? (>200)	Yes No
*Are you or anyone in your family diabetic?	Yes No
*Frequent episodes of dizziness or fainting?	Yes No
*Any known heart conditions? (Murmur, heart attack, surgery, mitral valve prolapse, angina, etc.)	Yes No
*If Yes, Please Explain.
*Asthma or other respiratory disorders?	Yes No
*Epilepsy or other seizures?	Yes No
*Any major surgerys in the last 12 months?	Yes No
*Are you taking medication regularly?	Yes No
*If Yes, Please Explain.
*Any head or neck issues?	Yes No
*Any other problems? (ie knee, hip, ankle, shoulder, back, etc.)	Yes No
*If Yes, Please Explain.
*What are your fitness goals?
*Which fitness service(s) are you interested in?	Personal Training Bootcamps Both
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