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ADK BOXING & FITNESS, LLC HEALTH QUESTIONNAIRE

GENERAL HEALTH QUESTIONS

Please read the 7 questions below carefully and answer each one honestly: check YES or NO.	YES	NO
1) Has your doctor ever said that you have a heart condition OR high blood pressure ?
2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).
4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? PLEASE LIST CONDITION(S) HERE:
5) Are you currently taking prescribed medications for a chronic medical condition? PLEASE LIST CONDITION(S) AND MEDICATIONS HERE: {input
6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. PLEASE LIST CONDITION(S) HERE:
7) Has your doctor ever said that you should only do medically supervised physical activity?

If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION below. You do not need to complete Pages 2 and 3.

If you answered YES to any of the questions above, please consult with Greg Landon, Head Trainer and Coach and your primary physician to be medically cleared for physical activity.

I understand that if I am participating in Boxing or Boxing-related training, Personal Training, or Fitness Classes, I must disclose and medical or mental health conditions which may interfere with my ability to fully participate, or may be detrimental to my health. Failure to disclose this information may result in my dismissal from ADK Boxing & Fitness training programs.

Follow Global Physical Activity Guidelines for your age (https://www.who.int/publications/i/item/9789240015128).

You may be required to take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, consult with Greg Landon, Head Trainer and Coach.

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