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Health Questionnaire

Please fill out the following form to help us understand your physical condition.

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?
Has your doctor ever said that you have a heart condition and recommended only spervised activity?
Do you have chest pain brought on by physical activity?
Have you developed chest pain in the last month?
Do you tend to lose consciousness or fall over as a result of dizziness?
Do you have a joint or bone problem that could be aggravated by the proposed physical activity?
Has a doctor ever recommended medication for your blood pressure or a heart condition?
Are you aware, through your own experience, or from a doctor's advice, of any other physical reason why you should not exercise without medical supervision?
Are you currently, or have you been pregnant in the last six monts?

Thanks for submitting!

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