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Health Questionnaire and Waver Form

Thank you for filling out this health questionnaire and waver form. 

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Dear SSB and Fitness Friday Athlete:

It is very important for me, in order to keep you and your fellow students safe and healthy, to be aware of any medical conditions that might be or become problematic for you while participating in this physical activity. For this reason, I really appreciate you completing this questionnaire. I know this form is a little lengthy, but you will only have to fill it once-a-year, and it is for your safety!

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YOUR INFORMATION IS AND WILL REMAIN CONFIDENTIAL

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I will contact you if I see any concerning information that I feel I need to discuss with you directly.

Health QUESTIONNAIRE AND Waiver FORM
for Fitness Course

To register for this class please fill out the following questionnaire and medical waver - Thank you!

Have you filled out this form since September 2021?
1) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
2) Do you feel pain in your chest when you do physical activity?
3) In the past month, have you had chest pain when you were not doing physical activity?
4) Do you lose your balance because of dizziness or do you ever lose consciousness?
5) Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
6) Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
7) Do you know of any other reason why you should not do physical activity?

Thanks for submitting!

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