APPLICANT INFORMATION













EMPLOYMENT INFORMATION - IF APPLICABLE




EMERGENCY CONTACT INFO







MEMBERSHIP



FITNESS GOALS - CHECK ALL THAT APPLY



MEDICAL


1. Have you ever suffered from any serious physical disability?
 
2. Epilepsy
 
3. Asthma/Eczema/Hay Fever
 
4. Shortness of breath
 
5. Diabetes
 
6. High Blood Pressure
 
7. Heart problems/chest pain/angina
 
8. Have you recently been in a serious accident or undergone surgery?
 
9. Have you ever suffered from any back/neck problems?
 
10. Have you ever suffered from any shoulder problems?
 
11. Have you ever suffered from any knee problems?
 

LIFESTYLE


1. Have you ever been a member of a gym/fitness club before?
 
2. Do you smoke?
 
3. Do you drink?
 
4. If yes, how often (eg: 3 times a week)?
5. If applicable, have you been pregnant in the last six months?