Name *

First Name

Last Name

Within the past 6 months, have you had a diagnosis of/treatment for heart disease or stroke, or pain/discomfort/pressure in your chest during activities of daily living or during physical activity? *

Yes

No

Within the past 6 months, have you had (a) diagnosis of/treatment for high blood pressure (BP), or a resting BP of 160/90 mmHg or higher? *

Yes

No

Within the past 6 months, have you experienced dizziness or lightheadedness during physical activity? *

Yes

No

Within the past 6 months, have you experienced shortness of breath at rest? *

Yes

No

Within the past 6 months, have you experienced loss of consciousness for any reason? *

Yes

No

Within the past 6 months, have you experienced a concussion? *

Yes

No

Do you currently have pain or swelling in any part of your body (such as from an injury, acute flare-up of arthritis, or back pain) that affects your ability to be physically active? *

Yes

No

Has a health care provider told you that you should avoid or modify certain types of physical activity? *

Yes

No

Do you have any other medical or physical condition (such as diabetes, cancer, osteoporosis, asthma, spinal cord injury) that may affect your ability to be physically active? *

Yes

No

Privacy and Use of Information: The information you provide in this form will be used solely to help determine whether you may require medical clearance prior to your first training session. We will not share or retain your information beyond this screening process. Responses provided here are non-binding and will not be used as official documentation. *

I understand.

Non-Binding and Informational Only: This pre-screening is for informational purposes only and does not constitute medical advice or an official assessment of your health. Any determination that you may need medical clearance is preliminary, and you are responsible for obtaining any necessary medical approval independently prior to training. *

I understand.

Consent: By submitting this form, you confirm that you understand its purpose and limitations. You consent to the temporary collection and review of your responses for preliminary screening purposes. If any questions raise a concern about your ability to safely participate, we recommend seeking medical advice before beginning training. *

I understand.