I'm Possible Fitness Questionnaire

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
I'm Possible Fitness Questionnaire
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-Mail Address*
Cell Phone
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

Do you feel pain in your chest when you perform physical activity?

In the past month, have you had chest pain when you were not performing any physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

Do you know of any other reason why you should not engage in physical activity?

I have read and understand the Release of Liability Agreement below.*