Step 1 of 2Health History QuestionnairePlease provide us with a little bit of information on you and your medical history Step 1 Health History Questionnaire Athlete's Name * Provide the name of the athlete that will be training. First Name Last Name Age * Date of Birth * MM DD YYYY Parent or Guardian * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Have you seen a doctor in the past year for any medical problems? * Yes No Have you ever experienced chest pain, "racing heart", irregular heartbeat, difficulties breathing or catching your breath while exercising or playing a sport? * Yes No Have you ever experienced nausea, dizziness, severe cramping or fainting from heat which forced you to stop the activity? * Yes No Have you ever passed out during a sport activity/exercise or lost consciousness due to a head injury? * Yes No Have you ever had sports induced asthma? * Yes No Do you have diabetes? * Yes No Have you pulled or strained a muscle within the past year? * Yes No Are you currently taking any medication? * Yes No Is there any condition that might limit your participation in this program? * Yes No In the past 3 years, have you had any injuries, surgeries or problems with the following areas? Low Back Neck Ankle Knee Shoulder Other Are you currently involved or ever been previously involved in a strength program? * Yes No ** I certify that the above information is accurate to the best of my knowledge. Please print your name below: * Thank you!
