Name * First Name Last Name Phone (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country DOB: MM DD YYYY Height * Weight Physician Physician's Phone (###) ### #### Emergency Contact Relationship Emergency Contact's Phone (###) ### #### Are you currently taking any medications that affect your heart rate or might otherwise interfere w/ exercise? * Do you smoke? Yes No Are you allergic to latex? (some equipment is made with it) Yes No Please describe any physical problems or injuries that concern you: What exercise do you currently do, and how often? Have you recently gained or lost a significant amount of weight? Are you interested in nutrition and/or health coaching as part of your training program? Do you have or have you had any of the following: Chest pain (during exercise and/or rest) Coronary heart disease Irregular heartbeat High blood pressure Family history of heart disease Rheumatic fever High cholesterol Respiratory problems Shortness of breath Chronic cough Diabetes Dizziness or loss of consciousness Seizure or convulsions Severe headaches Obesity Arthritis Serious bone, joint, or muscle injury Low back pain Relevant surgery If you have had a relevant surgery, please explain - what, when why? What does your physician or physical therapist recommend? Do you have any concerns or anything else I should know about? * By checking this box, I hereby certify that the above information is true and accurate. DIGITAL SIGNATURE * First Name Last Name Date * MM DD YYYY Thank you!Sebastian Grubb(831) 278-1045sebastiangrubb@gmail.comwww.sebastiangrubb.com Medical History QuestionnairePLEASE CONSULT YOUR PHYSICIAN BEFORE BEGINNING ANY EXERCISE PROGRAM.
