GYM MEMBERSHIP & PERSONAL TRAINING PATIENT EVALUATION FORM

First Name *

Last Name *

Date of birth *

In which state do you reside? *

Cell Phone number *

Email *

Are you 18 years of age or older?(NO will disqualify you from approval) *

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?(YES will disqualify you from approval) *

Do you feel pain in your chest when you do physical activity?(YES will disqualify you from approval) *

In the past month, have you had chest pain when you were not doing physical activity?(YES will disqualify you from approval) *

Do you lose your balance because of dizziness or do you ever lose consciousness?(YES will disqualify you from approval) *

Do you have a bone or joint problem that could be made worse by a change in your physical activity?(YES will disqualify you from approval) *

Is your average blood pressure greater than 160/100?(YES will disqualify you from approval) *

Do you know of any other reason why you should not do physical activity?(YES will disqualify you from approval) *

Are you pregnant or planned to be pregnant in the next 12 months?(YES will disqualify you from approval) *

* You are required to review the TELEHEALTH INFORMED CONSENT AGREEMENT and Medpaid LLC terms & conditions before this form is submitted.

Agreement to above TELEHEALTH INFORMED CONSENT AGREEMENT *

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Sign your name in the space above

I have read, reviewed, and accepted the above TELEHEALTH INFORMED CONSENT AGREEMENT and Medpaid LLC terms & conditions. By providing my phone number and email, I agree to receive text messages and emails from the business.

FSA/HSA Provider *