Participant’s Medical Information First Name *Last Name *Email Address * Have you previously or do you currently have: Low or high blood pressure *YesNoAsthma *YesNoDo you carry an inhaler? *YesNoBack problems *YesNoPlease describe back problems *Knee problems *YesNoPlease describe knee problems *Dizziness, fainting spells *YesNoSevere abdominal or menstrual cramps *YesNoEmotional impairment or disability *YesNoImmunizations current? *YesNoThyroid trouble *YesNoEpilepsy or convulsions *YesNoADD or ADHD *YesNoAre you currently pregnant? *YesNoAre you presently using any medicines, alcohol, or drugs? *YesNoPlease list medicines or drugs *Heart Problems *YesNoPlease list heart problems *Allergies *YesNoPlease list alergies *Recent sprains, fractures, or dislocations *YesNoPlease describe sprains, fractures, or dislocations *Diabetes *YesNoType/Treatment *Current communicable diseases *YesNoPlease describe communicable diseases *Date of Birth *Height *Weight (LBS) *Sex *FemaleMaleOtherDietary Restrictions/Food AllergiesInsurance Carrier *Policy Number *Doctor *City *Phone *Emergency Contact #1 *Relationship *Phone *Emergency Contact #2 *Relationship *Phone *Submit
