Will you agree to stay off your phone for the 45 minutes of class except for emergencies?
*
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Cel. Phone
(###)
###
####
Birthdate
*
How did you hear about my boot camp?
*
Which class do you prefer?
*
I prefer that you choose one class, but if your schedule does not allow for this, please contact me, and we will work out something for you.
When would you like to start? Camps can be prorated if necessary.
Name and number of physician
*
Has your doctor ever said that you have a heart condition and that you should only perform physical training under the care of a doctor?
*
Have you had chest pain in the past month while not performing 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?
*
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition
*
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
*
Do you know of any other reason why you should not engage in physical activity? If so, please let me know here.
*
Has a physician ever diagnosed you as having high blood pressure?
*
Are you on blood pressure medication?
*
Do you have high cholesterol?
*
Do you smoke?
*
Do you have diabetes?
*
Has anyone in your immediate family suffered coronary or atherosclerotic disease before age 55?
*
Are you pregnant?
*
Do you have any physical limitations that would limit your ability to exercise? If so,what are they?
*
List dates, reasons, and outcomes of any surgeries, abnormal test results, and hospitalizations which you might believe would relate to boot camp training.
*
Your digital signature and date
*
On a scale of 0-10, how important is making this change to you?
On a scale of 0-10, how confident are you that you can make this change?
What type of physical activity are you currently doing?
*
What supplements are you currently taking? Vitamins, protein powder, etc.?
What do you like to do for fun?
What are your fears or worries about training/boot camp?