Name *

First Name

Last Name

Phone *

(###)

###

####

Name *

First Name

Last Name

Phone *

(###)

###

####

1. Do you have any current or past medical conditions (e.g. heart disease, diabetes, high blood pressure, osteoporosis, arthritis) *

Yes

No

2. Have you had any surgeries or injuries in the past 5 years? *

Yes

No

3. Are you currently taking any medications? *

Yes

No

4. Do you have any allergies (e.g. food, medication, environmental)? *

Yes

No

5. Do you experience any of the following? (Check all that apply)

Chest pain during exercise

Shortness of breath

Dizziness or fainting spells

Joint pain or swelling

6. Do you have any current physical limitations or injuries that may affect your ability to participate in certain exercises? *

Yes

No

I confirm that the information provided above is accurate to the best of my knowledge. I understand that it is my responsibility to inform KAAIAA staff of any changes to my health status. I acknowledge that if I have health concerns I should consult my medical professional prior to taking part in any form of physical exercise. *

I agree

I disagree

Date *

MM

DD

YYYY