Name *

First Name

Last Name

Asthma *

Yes

No

High Blood Pressure *

Yes

No

Pneumonia *

Yes

No

Diabetes *

Yes

No

Angina *

Yes

No

Heart Condition *

Yes

No

Heart Murmer *

Yes

No

Arrhythmia *

Yes

No

Dizziness *

Yes

No

Have you undergone any type of surgery *

If Yes, please list the surgery and date it was performed

Yes

No

Are you currently taking any medications? *

If Yes, Please list the medications in the text box below and the reasons for taking them.

Yes

No

Have you ever undergone any physical therapy or extended treatment for an injury? *

If yes, please explain in the text box below

Yes

No

Do you have any health or orthopedic conditions (hand, wrist, elbow, shoulder, ribs, back, hips, knees, ankles, or feet) which might limit your participation? *

If yes, please explain below.

Yes

No