Medical History Questionnaire

Freedom Fitness Speed Academy

Medical History Questionnaire

This Medical History Questionnaire, Registration Form, Membership Application, Liability Release Form. Fast Start Assessment and bootcamp payment must be completed before the registration process can be considered complete and boot camp can begin.

It is wise to seek your doctor’s advice BEFORE beginning any health/fitness/nutrition program!

* Required fields
Name *
E-mail Address *
Cell Phone *
Are you allergic to any medication? *
Do you take any medication on a regular or semi-regular basis? *
Do you have seizure disorder (epilepsy)? *
Do you have Type I or Type II diabetes? *
Have you ever been diagnosed with anemia? *
Do you have high blood pressure? *
Do you have or have you ever had Heart Disease? *
Do you have or have you ever had Lung Disease? *
Do you have or have you ever had Liver Disease? *
Do you have or have you ever had Kidney Disease? *
	Do you have or have you ever had asthma? *
Do you have or have you ever had a severe neck injury? *
Have you ever been rendered unconscious? *
Do you wear contact lenses or glasses? *
Have you ever injured your back? *
Do you have back pain? If yes, how often?	Almost never Seldom Occasionally Frequently with vigorous exercise
Have you had a broken bone or fracture in past 2 years? *
Have you had knee pain in the past 2 years that has disabled you for more than a week? *
Do you have any physical conditions that cause pain? *
Have you had any surgical procedures? *
Have you ever had your body fat tested? *
Are you training for a specific event? *
If you answered yes to any questions, please explain here:
Comments
I have read and agree to the Privacy Policy *

Photographs and videos may be taken during Freedom Fitness Speed Academy and/or its affiliates activities and events. By participating, athletes and parents/guardians consent to the use of images, video, and audio recordings for promotional, educational, fundraising, and marketing purposes, including use on our website, social media platforms, and printed materials. If you do not wish for your athlete's image to be used, please submit a written request to the club prior to participation.