Medical Release Form

Your Name (required)

Your Email (required)

Subject- Medical Release Form

Your Age(required)

Your Weight(required)

Your Height(required)

_________________________________________

Medical History: (Required) Briefly Describe your Medical History Below: (Please note if you have any disease, heart attack, diabetes, high cholesterol, high blood pressure, etc.

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Medications & Supplements:(required). Please list any medications, vitamins, or supplements you currently take.

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Please Answer the Following Medical Questions:

1. Has your Doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?(required)
YesNo

2. Do You Feel Pain in your chest when you do any physical Activity?(required)
YesNo

3. In the Past month, have you had chest pain when you were not doing physical activity?(required)
YesNo

4. Do You Lose your Balance because of Dizziness or do you ever lose consciousness?(required)
YesNo

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?(required)
YesNo

6. Is your Doctor Currently prescribing Drugs (For example, waterpills, for your blood pressure or heart condition?)(required)
YesNo

7. Do you know of any other reason why you should not do physical activity?
YesNoNot Sure

If you Answered "YES" to 1 or more questions, please talk to your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor which questions you answered "YES" To.

“I have read, understood and completed the questionnaire. Any
questions I had were answered to my full satisfaction.”

I agree to share this information with Jon Gustin and begin my 6 – 12
week nutritional/ fitness program.

Please Enter the 4 Character 'CAPTCHA' Below (To Prevent Spam) and then click the SUBMIT Button Below to Complete This Medical Release. Thank you!

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