Join a Drop-in!
In order to fully support you, please answer honestly. We take your safety and privacy seriously. Responses are only shared with other medical professionals in the event of emergency.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Check any that apply to conditions you are or have experienced:
*
Asthma or Respiratory Conditions
Osteoporosis / low bone density
High or low blood pressure
Cardiac disease
Diabetes
Allergies to pollens
Psychiatric disorder
Allergies to insect stings
Stress-related anxiety
Other
NOT AWARE OF ANY CONDITIONS
Please explain conditions you checked, and how you manage them:
Do you experience any issues with walking, stepping up, stepping down, or mobility in general?
*
Yes
No
Please explain your mobility issues:
Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?
*
Yes
No
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
*
Yes
No
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?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you know of ANY OTHER REASON why you should not do physical activity?
*
Yes
No
Please explain the reason you should not do physical activity:
Are you currently taking any prescription medication?
*
Yes
No
Please prescribed medications:
Are you signing for a participant who is under the age of 18?
*
Yes
No
FOR PARTICIPANTS OF MINORITY AGE: Confirm and click/tap to "check" below
*
This is to certify that I, as Parent, Guardian, Temporary Guardian with legal responsibility for this participant, do confirm that the above statements are complete and accurate.
Signature
*
Continue
Continue
Should be Empty: