Health Declaration

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

Are you experiencing any flu symptoms?

No

Yes

Date

Initials

Health Hisotry

Any heart conditions?

Chest pain from activity?

Blood pressure or heart medications?

Joint problems aggravated by activity?

Thru your knolwdge or your doctor's are there any medical reason not to excercise?

Are you over 65 and not used to rigorous activity?

If any above are yes, will you consult your physician before increasing activity?

I confirm that the information given in this form is true

Thanks for submitting!

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