See and Feel the Difference Registration Form

Emergency Contact Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Age*

I would be happy if I could lose*

Systolic Blood Pressure Reading (if checked within last 6 months)*

Have you ever been diagnosed with heart problems?*

Have you ever had pressure, pain, or tightness in your chest as a result of overexertion?*

Have you ever had irregular or uneven heartbeats?*

Do you suffer from shortness of breath, requiring you to stop activities which do not seem to affect others in the same way?*

Have you ever had a heart attack?*

Have you had any kind of heart surgery?*

Do you have any family history of cardiovascular disease?*

If yes, please indicate the age of the family member*

Have you ever smoked any kinds of tobacco?*

If yes, please indicate correct history*

Current physical activity level*

Have you ever suffered from an eating disorder?*

If yes, please indicate correct history*

Are you currently pregnant or given birth less than 6 weeks ago?*

If yes, please indicate due date or child's birth date

MonthDayYear

Please indicate use of the following medications*

	Never	Within last 12 months	Currently
Blood thinners
Cholesterol lowering
Nitroglycerin or dilators
Digitalis
High blood pressure
Tranquilizers
Antihistamines
Insulin for diabetes

Do you suffer from any of the following?

Assumption of Risk*

First NameLast Name

Please read the following statement carefully:

By the electronic input of my name, I declare I am an individual over the age of eighteen, and do hereby willfully and knowingly waive any and all personal liability claims against See and Feel the Difference, its representatives, agents or any successor entity, which may arise due to my participation in said program. I understand that this is a strenuous and demanding exercise program. I have been advised to confer with a physician if I have any concerns regarding my ability or susceptibility to injury, to determine that I am fit and able to participate in such a program. I intend for this statement to be binding upon my successors and heirs, and hereby agree to hold See and Feel the Difference harmless for any and all expenses and/or judgments which may arise, including but not limited to, reasonable attorney's fees and court costs. I have read and understand the foregoing personal liability waiver and assumption of risk statement.

See and Feel the Difference Registration Form

Health History Form