VFit Medical Form
Medical Information
First Name:
Last Name:
Phone:
Cell Phone:
Emergency Name and Number:
Email:
Address:
Add City & State
Date of Birth:
ex: 08-25-80
How were you referred to Vitality Fitness?
Level of Activity:
Scale of 1-5
(5 being the most)
Notes on Activity:
Hypertension
:
Have you ever been diagnosed with high blood pressure?
Yes or No?, If Yes, Explain
Do you Smoke?
If yes, explain (when, how long, when did you quit, etc)
Heart
Have you ever been diagnosed with heart problems?
Please type in yes or no.
If yes, please explain:
Joints
Any injuries or surgeries we should be aware of?
If yes, please explain:
Other medically relevant info?
Physician
Your Physician's Name
Phone Number:
Anything we should know?
Click here to print out our Release of Liablity Form Word Doc
