SK Strength Coach

1

Full Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Area Code

Phone Number

3

E-mail* This field is required.

example@example.com

4

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?* This field is required.

Yes

No

5

Do you feel pain in your chest when you do physical activity?* This field is required.

Yes

No

6

In the past month, have you had a chest pain when you were not doing physical activity?* This field is required.

Yes

No

7

Do you lose balance because of dizziness or do you ever lose consciousness?* This field is required.

Yes

No

8

Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity?* This field is required.

Yes

No

9

Is your doctor currently prescribing medication for your blood pressure or heart condition?* This field is required.

Yes

No

10

Do you know of any other reason why you should not take part in physical activity?* This field is required.

Yes

No

11

If yes to any of the above, please comment:

12

Signature