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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.
Submit
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