11b99862-ce1f-4130-a676-1600434c268b
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Personal Information
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951b1e4a-2b59-4eaa-8e49-be7dee6cd628
Textbox
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f0069a75-4293-41de-8005-373041ef1668
Textbox
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Your Name:
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*
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8dcf9a53-2b7c-4dd0-b32a-d473b6049928
Textbox
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Property Address:
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*
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8facf391-2fca-4619-814f-fb3c8390085f
Textbox
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Email Address:
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*
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d79ff24b-8fc4-4aca-b412-5e686e5de3d5
Textbox
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Cell Phone:
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*
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c082eb15-a03d-49e6-9e57-e47a5dc64760
Textbox
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Home Phone:
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b040339c-3d1e-4edb-961b-7ae0b197c346
Textbox
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Birth Date:
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*
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a413cc70-4944-4c1c-a1a4-b1434929cf97
Dropdown List
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Age:
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*
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2ca042d1-3352-4735-a765-6b9a8127d4b6
Dropdown List
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Gender:
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*
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4a0ab75c-4f0c-4470-bd64-52ffec28fe18
Textbox
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Relationship to Property Owner:
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*
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9c04fc80-4195-4c5d-9ef9-d4682a5f2f68
Dropdown List
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Own (Primary residence):
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*
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07032278-c380-4683-a8c1-bf3d4ac1bf6a
Dropdown List
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Own (Secondary home, to be used as rental)
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*
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d47feece-5859-47ad-a776-f970336f77e5
Dropdown List
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Lease/Rent
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*
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c94a0903-6856-4662-a9a1-334d59c90b13
Textbox
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If yes, month/year lease ends:
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c2235a31-34ae-4111-928c-14f5e08acb46
Textbox
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Emergency Contact Name:
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*
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11efeea9-c3bf-4198-9467-f14bc901d32c
Textbox
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Emergency Contact Phone:
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*
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29ccd410-529b-4ca8-be7b-763a0952f09e
Label
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Questionnaire
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40d1fc2b-7c62-4df2-91e8-0a109e09f959
Inline Text
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Common sense is your best guide in answering these few questions. Please read them carefully and check the correct answer opposite the question if it applies to you.
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38a94f52-e06b-4deb-8461-d5010ab83c3b
Dropdown List
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Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
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*
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3c6a1583-0526-4b69-a2e3-82d8dfc5983a
Dropdown List
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Do you feel pain in your chest when you do physical activity?
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*
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4c889f8b-41e5-49fa-94f2-5fbd30d94d6e
Dropdown List
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In the past month, have you had chest pain when you were not doing physical activity?
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*
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c3527288-9752-4dee-9bec-4d5d0a9dcb24
Dropdown List
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Do you lose your balance because of dizziness or do you ever lose consciousness?
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*
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85b98738-ae18-415a-ae7a-e3fca5964f1d
Dropdown List
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Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
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*
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386d8e05-4e31-412b-85a3-19e3be2617fe
Dropdown List
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Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
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*
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bf54391e-ec95-4601-a6c7-310a473e9de3
Dropdown List
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Do you know of any other reason why you should not do physical activity?
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*
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c9438224-b5f2-48c9-a81d-303a3db4934c
Inline Text
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If you answered yes to one or more of these questions, we strongly recommend that you see your doctor before you start becoming much more physically active or before you have a fitness assessment.
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a01bab90-e803-419c-a0f6-cba0d7aa3211
Label
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Acknowledgements
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75514992-e4f3-4a45-8815-494d2b7102e8
External Link
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Click here to download and read the: Access Card Use and Acknowledgement of Risk
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78520be8-c3c5-486a-a5e6-b63d9d74b64b
Electronic Signature
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e9c4a10b-0860-461d-a26d-a0f0726f394e
Textbox
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