Your First Name (required)

Your Last Name (required)

Your Email (required)

Gender

Physician's Name/Address/Phone/Fax/email

Please answer Yes/No to each question:
Are you on any medication or drugs?: YesNo
If yes, please list the medications AND the condition for which they have been prescribed (at the end of this form).

Do you have now (or have you ever had) heart problems, chest pain, or stroke? YesNo

Do you feel pain in your chest when you do physical activity? YesNo

Have you had chest pain when not doing physical activity? YesNo

Do you have (now and/or have you ever had) increased blood pressure? YesNo

Do you have (now, or have you ever had) any chronic illness or condition? YesNo

Do you have (now, or have you ever had) any difficulty with physical exercise? YesNo

Have you ever been given advice from a physician not to exercise? YesNo

Within the past 3 months, have you been (or are you now) pregnant? YesNo

Do you have now or have you had breathing or lung problems? YesNo

Do you have muscle, joint, back disorders, or any previous injury still affecting you, that could be made worse by a change in your physical activity? YesNo

Do you have (now, or ever had) Diabetes or a Thyroid condition? YesNo

Did you ever, or do you now, smoke cigarettes? YesNo

Were you ever, or are you now, considered overweight (20% over ideal bodyweight)? YesNo

Do you have (now, or have you ever had) increased blood cholesterol? YesNo

Do you have (now, or have you ever had) a Hernia or other condition aggravated by lifting weights? YesNo

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

Do you know of any other reason why you should not do physical activity? YesNo

In the space below, please list prescriptions and what they've been prescribed for

In the space below, please list the details for any question which you answered "yes" to above.

How many days a week do you do cardiovascular activity:
—Please choose an option—1234567

How many days a week do you do resistance training:
—Please choose an option—1234567

On a scale of 1-5 (1 = sedentary, 5 = Active), how would you describe your overall daily activity?
—Please choose an option—12345

Can you perform at a minimum 20-30 minutes of slow steady walk/bike? YesNo

What obstacle, if any, is there between you and exercising regularly?

Does your family physician know you are taking part in this program? YesNo

By filling out this form, I hereby give informed consent to engage in Flipping 50’s Stronger Program, including participating in a variety of recommended physical activities and education about weight loss science with nutrition, exercise, and lifestyle habits. The program is designed by, and
recommendations/modifications will be made by, a trained Medical Exercise Specialist and Personal Trainer. Recommended activities will include weight training, cardiovascular activity, light cardio and stretching.

I have read this form and understand that there are inherent risks associated with any physical activity. I recognize that it is my responsibility to provide accurate and complete medical/health history information. Furthermore, it is my
responsibility to monitor my individual physical performance during any activity.

Yes answers to questions on the Health History may mean it is recommended I seek the approval of a physician before beginning. If I choose to participate without a physician’s approval, I assume any risk with my involvement.

Above all, I realize that not participating in a health program carries more risk! I’m in!

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