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Personal Information
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Your Name:
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*
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2941adda-e55c-434f-84e0-8bfc1773b8ca
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Property Address:
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*
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4945f398-daba-4349-bc52-5f2d9d58999d
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Email Address:
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*
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f45d716c-9f06-4143-b85f-d1134415620f
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Cell Phone:
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*
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Home Phone:
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Birth Date:
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*
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Age:
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*
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Gender:
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*
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Relationship to Property Owner:
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*
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Own (Primary residence):
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*
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Own (Secondary home, to be used as rental)
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*
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Lease/Rent
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*
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765fa814-15f7-43e3-ab64-c8e8d1d899cc
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If yes, month/year lease ends:
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Emergency Contact Name:
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*
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Emergency Contact Phone:
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*
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9ab573ff-181b-41ba-aac2-fbe3301d81ee
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Questionnaire
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30e7b1c2-ad01-4efe-bc2e-c49d8e889be7
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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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Do you feel pain in your chest when you do physical activity?
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*
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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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Do you lose your balance because of dizziness or do you ever lose consciousness?
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dbcd8f54-6763-452c-8c70-f262ffde60b7
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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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adb383f4-b321-4bbd-acf3-206bab6b4cdf
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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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741a0649-4747-4265-a3d3-cd99cf5c0602
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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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Acknowledgements
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e4d20dcb-72dc-4277-9db8-20459859eb77
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Click here to download and read the: Access Card Use and Acknowledgement of Risk
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