FAT Program Registration

The Fitness and Tranquility Program Registration Form -

Fill out this form if you are a Veteran that wants to reignite that warrior spirit and regain your confidence with a regular workout regiment, a healthy diet, and to help establish the connection to a balanced mind, body, and spirit.
Physical Fitness Disclaimer

You should always consult your physician or other healthcare provider before changing your diet or starting an exercise program.
Name*

First NameLast NameSuffix
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Medical Questions

ANY FORM YOU MAY FILL OUT HERE ON OCB'S WEBSITE IS HIPAA COMPLIANT. YOUR INFORMATION IS PROTECTED.
Birth Date

MonthDayYear
Date
Height?
Current Weight?
in lbs
Do you have diabetes?

YesNoMaybe
Do you have a history of high blood pressure?

YesNoMaybe
Is body composition interfering with the performance of the simple of daily tasks? (i.e., clinically obese?)

YesNoMaybe
Do you have a family history of coronary disease before age 50?

YesNoMaybe
Do you? check all that apply

smoke (and over the age of 35)drink excessively (more than 1-2/day)use (or have used) illicit drugs / substanceshave poor sleeping habits (less than 8 hrs./night regularly)
What Are Your Medical and Surgical Histories?
We need to know whether you have ever been hospitalized, treated for a chronic condition, had medical tests, or had surgery. Even if an adult patient had surgery or some other treatment as a child, it's important to know about it when creating a treatment plan and delivering healthcare.
What Prescription and Non-Prescription Medications Do You Take?
We need to know not only about any prescription medications you take, but also over-the-counter medications, vitamins, and herbal supplements.
What Allergies Do You Have?
In addition to knowing whether you have seasonal or food allergies, we need to know if you have any drug allergies, a latex allergy, or a serious reaction to bee stings. This helps us be better prepared in the event you have a reaction while at our facility.

How happy are you knowing that you're on a path to becoming a healthier human being and maybe adding some years to your life while helping make your life better all around?*

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1 is Sad Face, 5 is Happy Face

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The Fitness and Tranquility Program Registration Form -

Physical Fitness Disclaimer

Medical Questions