|
0fce1a52-6880-44f1-9afe-5366a0c08916
Label
|
Personal Information
|
|
|
b6f033ff-734d-4f86-8e33-8cbf64b51e6c
Textbox
|
|
|
|
4ffcae88-3c68-49d9-9766-d189ec2cf985
Textbox
|
Your Name:
|
*
selection is required
|
|
faf47b9e-da24-4e75-ae15-b9a47ad30e2c
Textbox
|
Property Address:
|
*
selection is required
|
|
d76b7c4e-9172-4bbb-bf59-e01a68888c05
Textbox
|
Email Address:
|
*
selection is required
|
|
1c308c57-42f7-4901-a2ce-b51abaee931c
Textbox
|
Cell Phone:
|
*
selection is required
|
|
469bfc3e-b414-4e09-b108-4c554f52e857
Textbox
|
Home Phone:
|
|
|
78838c5b-b06d-403c-aeca-5aaaffea74f4
Textbox
|
Birth Date:
|
*
selection is required
|
|
943fb97d-44a7-4d74-be06-efd73132db32
Dropdown List
|
Age:
|
*
selection is required
|
|
a261aa39-bd2c-4ac5-9ff1-c4df1988b741
Dropdown List
|
Gender:
|
*
selection is required
|
|
b416d217-f432-4c3b-97a0-a6fe66aa3d2d
Textbox
|
Relationship to Property Owner:
|
*
selection is required
|
|
54dc5691-d031-49b6-834c-04a52fd86827
Dropdown List
|
Own (Primary residence):
|
*
selection is required
|
|
e75ba324-10ee-4d7c-a5e0-c9b8021d3cf7
Dropdown List
|
Own (Secondary home, to be used as rental)
|
*
selection is required
|
|
73f5ddcd-9279-42bf-bbed-811b911be762
Dropdown List
|
Lease/Rent
|
*
selection is required
|
|
179fc0fb-6b02-4b68-b760-745e9bb258dc
Textbox
|
If yes, month/year lease ends:
|
|
|
dd967c60-26d6-4128-8b9a-f493b9ee3d20
Textbox
|
Emergency Contact Name:
|
*
selection is required
|
|
e1ffabad-d86f-4e51-a90a-f529f1739f1f
Textbox
|
Emergency Contact Phone:
|
*
selection is required
|
|
6b6bf68a-66f2-496c-b459-510b65ce110a
Label
|
Questionnaire
|
|
|
0a2c58d4-cea1-4f0f-9e73-e659786ea1d6
Inline Text
|
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.
|
|
|
e07e5127-ca61-4cc5-a9a4-562a0860b849
Dropdown List
|
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
|
*
selection is required
|
|
2323348f-0e78-4e6a-95cf-5a1d22a9afef
Dropdown List
|
Do you feel pain in your chest when you do physical activity?
|
*
selection is required
|
|
e953551a-4dd3-4db4-a0bf-e3d3b38a63cb
Dropdown List
|
In the past month, have you had chest pain when you were not doing physical activity?
|
*
selection is required
|
|
34edd355-0674-4006-936a-4947e7d0d2ec
Dropdown List
|
Do you lose your balance because of dizziness or do you ever lose consciousness?
|
*
selection is required
|
|
ba074977-74b3-48cc-a5cd-78362a549ea1
Dropdown List
|
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?
|
*
selection is required
|
|
dc2e349e-cd0c-4994-ba44-eb4fbd68ae8c
Dropdown List
|
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
|
*
selection is required
|
|
6edd118f-daa4-4df2-8a71-1d7ca5272884
Dropdown List
|
Do you know of any other reason why you should not do physical activity?
|
*
selection is required
|
|
581cdb88-de64-40d0-a8fc-1b89136a95e4
Inline Text
|
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.
|
|
|
df5002e9-a4a3-4395-8ed3-11ebb83a09b6
Label
|
Acknowledgements
|
|
|
7a3f7924-f6db-4024-9536-57fc06941158
External Link
|
|
Click here to download and read the: Access Card Use and Acknowledgement of Risk
|
|
80aa9c4a-e413-44ee-b2ed-a068e94791eb
Electronic Signature
|
|
|
|
d48079b4-b211-42a7-a1aa-6141ed5bacb8
Textbox
|
Initials
|
*
selection is required
|
| | |
|