Monday Wednesday Friday First Name:  * Last Name:  * Email Address:  * Address:  * City:  * Zip Code:  * Phone  * Date of Birth  * Health Assessment   Date of last full physical?  *   Have you ever had any form of heart disease? yesnounsure   Have you ever experienced shortness of breath or chest pains? yesnounsure   Do you have or do any of the following pertain to your health? If yes please explain. If not please type N/A High blood pressure? Levels  *   Do you smoke cigarettes pipe or use tobacco products?  *   Diabetes? Type  *   Family history of heart disease? Who and age?  *   Do you work out regularly? How often  *   Are you currently taking any medication or herbal suppliment? Explain  *   Do you have problems in the following areas? Knees Lower Back Hip/Pelvis Other Please explain.  *   How did you hear about the class? OnlineFriendAdOther If other please describe.  * Comment Security code:   * Do not enter anything in this field: