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Assessment Form

Please fill out the following form

Fitness Goals

Rank each category on a scale of 1-10

10 signifies most important to you

Health History

High blood pressure (160/90 or on medication)? Required
Blood cholesterol (high: above 200)? Required
Diagnosed diabetic? Required
Frequent episodes of dizziness or fainting? Required
Know heart condition (heart attack, surgery, mitral valve prolapse or angina)? Required
Are you taking any medications regularly? Required
Asthma or other respiratory disorder? Required
Epilepsy or other seizure disorder? Required
Do you have any current injuries? Required
Do you smoke? Required
Surgery within the past? If yes please describe below Required

By checking this box, I accept responsibility for my use of any and all apparatus, facility, privilege or service whatsoever, at my own risk, and shall hold Shelby and Forever Better Health & Fitness harmless from any and all loss, claim, injury, damage, or liability sustained or incurred by me resulting therefrom.

Upon submission, I will review and get back to you within 48 hours with the next steps!

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