Serious Strength Address

   
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If you prefer, download the form below, fill it out at your leisure and bring it with you to your first session or email it back to us at: info@seriousstrength.com

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Health History Form
online form

Please answer to the best of your knowledge.

Type "YES" or "NO" to any questions in the spaces provided. If you answer YES to any entry, please explain in a sentence or two.

If you suspect you have had or if you currently do have cardiovascular and/or heart disease (CVD/CHD), you need a letter from your doctor clearing you for exercise. You can email this letter to info@seriousstrength.com or fax it to us 212 579-9321. Your physicians name and signature must be on the letter. Unfortunately, without this letter, we cannot put you through an exercise session. If you have any questions, please call 212-579-9320.

 

Personal Information:

* Your Name:

Today's Date:

Home Address:

Work Address:

Day Phone:

Evening Phone:

Cell Phone:

* Your Email:

Occupation:

Company:

Sex:

Height:

Weight:

Date of Birth:

3 Favorite Hobbies/Interests:

If Applicable:

Anniversary Date:

Children's Names and Ages:

in case of emergency, who should we contact?

Name:

Phone:

Relationship:

Physician's Name:

Physician's Phone:

How did you hear about Serious Strength?

Specify:

Current physical activity:

Type:

How Often:
Conditions:

Do you have any history of heart problems?

Do you have a current heart condition?

Have you ever had a heart attack or stroke?

Have you ever experienced chest pains?

Do you have high or low blood pressure?

Do you have arthritis?

Do you have high cholesterol?

Are you pregnant now or within the last 3 months?

Any medical procedures within the last 12 months?

Do you experience dizziness or fainting?

Do you have asthma or any respiratory problems?

Do you have Diabetes or a thyroid condition?

Do you have or have you had a hernia of any kind?

Are you taking any medications?

Do you have a chronic illness or condition?

Other?

Injuries:

Have you ever had any lower back problems?

Do you have any neck problems?

Do you have or have you had any other joint or muscle problems?

Other:

Are you currently under the care of a physician for any reason at all?

Do you smoke cigarettes, cigars, or other?

Do you use drugs and/or alcohol?

Are you currently taking any dietary supplements?

Does your doctor know that you are beginning a new exercise program?

If yes to the above question, does he/she object?

Do you know of any other physical or mental condition that you have or have had that could be aggravated, worsened, exacerbated, inflamed, etc., by exercising or exerting yourself?

Confirmation:

Please read this waiver in its entirety before submitting. Do not submit this waiver if any part of it is
not clearly understood:

I certify that the above statements are true and complete. Furthermore, I have had a medical
examination within the last year that verified that I am in good health and able to participate in a
strenuous physical conditioning program. I release Serious Strength, Inc., from all claims, injuries,
damages, illnesses, actions or causes of action, and from all acts of active or passive negligence on
the part of the company, corporation, club, its owners, solvents, agents, trainers, instructors,
independent contractors or employees. I acknowledge that Serious Strength, Inc. will rely on my
statements and representations.

* By typing the word "accept" below, I certify that (1) all responses to the questions above are correct (2) are answered to the best of my ability (3) I accept the agreement above.

All fields marked with a (*) are required.

 
 

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