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CLIENT QUESTIONNAIRE
& PRE SCREEN
Name
Gender
Email
Date of Birth
Family history of heart disease?
*
No
Yes
Do you smoke?
*
No
Yes
Do you have high blood pressure?
*
No
Yes
Are you taking medication
*
No
Yes
Do you have or had any injuries we should know about
*
No
Yes
Do you regurly exercise?
*
No
Yes
Please specify anything we should know about
Your Signature
Clear
I declare that the info I’ve provided is accurate & complete
I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.
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