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Health Waiver

To register for services please fill out the following medical information. This waiver will cover January 1, 2026 - December 31, 2026 and must be filled out once each calendar year for participation.

Full Name of the PARTICIPANT ONLY

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

Do you feel pain in your chest when you do physical activity? *

Yes

In the past month, have you had chest pain when you were not doing physical activity? *

Yes

Do you lose balance because of dizziness or do you ever lose consciousness? *

Yes

Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity? *

Yes

Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition? *

Yes

Do you know of any other reason why you should not do physical activity? *

Yes

I acknowledge that the information provided is true, accurate, and complete to the best of my knowledge as of today’s date. I understand that I am solely responsible for notifying Energy Fitness of America of any changes or updates to this information, including any relevant health-related conditions or concerns. Energy Fitness of America shall not be held responsible for any issues resulting from my failure to provide updated or accurate information for the current calendar year.

Today's Date

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