Student Information

E-mail:  
First and Last Name:    
Student ID:   Only use numbers. No spaces, hyphens or parenthesis.
Which class are you enrolled:  
Address:  
City:  
Zip:  
Home Phone:   Numbers only! If you do not have a home phone, write "No Home Phone"
Cell Phone:   Numbers only! If you do not have a cell phone, write "No Cell Phone"

In case of an emergency, who should we contact (preferably a parent)?

First and Last Name of Emergency Contact:    
Contact Phone:   Numbers only! Please use a cell phone number if possible.
Relationship:  
What is your resting heart rate:   Take your heart rate for one full minute. 
Your resting heart rate should be between 60 and 90 beats per minute.
How much do you weigh?  
How tall are you?          
Date of Birth:   Only numbers! Use the following format: "mmddyy"
Age:  
Gender:  

Do you take any medications?:

 

Please list all the medications you are currently taking:

Do you have any allergies?

 

Please list all of your allergies:

Do you have any medical problems?

 

Please list all of your medical problems:

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?  
If yes, explain:
Do you feel pain in your chest when you do physical activity? 
If yes, explain:
In the past 30 days, have you had chest pain when you were not doing physical activity?
If yes, explain:
Do you lose your balance because of dizziness or do you ever lose consciousness?
If yes, explain:
Do you have bone or joint problems that could be made worse by a changing your physical activity?
If yes, explain:
Is your doctor currently prescribing medication for your blood pressure or heart condition?
If yes, explain:
Do you have diabetes?
If yes, explain:
Do you have asthma? If yes, you must carry your inhaler with you at all times, NO EXCEPTIONS!
If yes, explain:
Are you pregnant?
If yes, explain:
Do you have problems with seizures?
If yes, explain:
Do you smoke cigarettes? 
If yes, how many per day?
Do you, or any member of your family, have a history of heart disease?
If yes, explain:
Do you know of any other reason why you should not do physical activity?
If yes, explain: