New Member Information Step 1 of 2 – General Information 50% Name(Required) First Last Address(Required) Street Address City ZIP Code Date of Birth(Required) Month Day Year Email(Required) Cell Phone(Required)Emergency Contact(Required) First Last Relationship(Required) Emergency Contact Phone(Required)How did you hear about us?(Required)Facebook / InstagramGoogleMindBody appSomeone referred MeOtherTell us who referred you so we can say, 'Thank you!'(Required) Tell us how you heard about us so we can update our database.(Required) Please take a minute to describe your fitness goals.Do you currently exercise? Yes No Briefly describe how often you exercise and what that exercise consists of. On this questionnaire, a number of questions regarding your physical health are to be answered. Please answer every question as accurately as possible so that a correct assessment can be made. Please ask if you have any questions. Your responses will be treated in a confidential manner.Do you have any personal history of heart disease (coronary or atherosclerotic disease)?(Required) Yes No Any personal history of diabetes or other metabolic disease (thyroid,renal,liver)?(Required) Yes No Any personal history of pulmonary disease, asthma, interstitial lung disease or cystic fibrosis?(Required) Yes No Any unaccustomed shortness of breath (perhaps during light exercise)?(Required) Yes No Have you had any problems with dizziness or fainting?(Required) Yes No Do you have difficulty breathing while standing or sudden breathing problems at night?(Required) Yes No Have you experienced a rapid throbbing or fluttering of the heart?(Required) Yes No Do you suffer from ankle edema (swelling of the ankles)?(Required) Yes No Have you experienced severe pain in leg muscles during walking?(Required) Yes No Do you have a known heart murmur?(Required) Yes No Are you a cigarette smoker?(Required) Yes No Would you characterise your lifestyle as "sedentary"?(Required) Yes No Are you 20% or more overweight or have you been told your "BMI" was greater than 30?(Required) Yes No Do you have any family history of cardiac or pulmonary disease prior to age 55?(Required) Yes No Do you have any back pain or joint pain?(Required) Yes No Have you ever had a major surgery?(Required) Yes No Please tell us about the surgery.(Required)Do you have any injuries coming into your workout?(Required) Yes No Please describe your injuries.(Required)
