Name:                                                             		Date:

Medical History
1. Are you pregnant? (women only)  No  Yes 
2. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
No  Yes 
If yes, list medications:________________________________________________

3. Do you take any prescribed medication (aspirin, penicillin, sulfa, etc.)?  
No  Yes 
If yes, list medications:________________________________________________

4. Do you have a seizure disorder (epilepsy)?      No  Yes 

5. Do you have diabetes (adult or juvenile)?	   No  Yes 
If yes, list type and medications:__________________________________________

6. Have you ever been found to be anemic (low blood count)?   No  Yes 

7. Do you have High Blood Pressure (Hypertension)?   No  Yes 
If yes, list medications: ________________________________________________

8. Do you have or have you ever had the following diseases?
	Heart Disease?  No  Yes 
	Lung Disease?  No  Yes 
	Kidney Disease?  No  Yes 
	Liver Disease?  No  Yes 

9. Do you have asthma?  No  Yes 
If yes, list medications: ________________________________________________

10. Have you had a broken bone or facture in the past 2 years?  No  Yes 
If yes, describe:________________________________________________

11. Have you ever suffered from a back injury?  No  Yes 
If yes, describe:________________________________________________

12. Do you continue to suffer from back pain?  No  Yes 
If yes, how often:________________________________________________

13. Have you had knee pain in the past 2 years that has disabled you for longer than a week?  
 No  Yes 
If yes, describe:________________________________________________

14. Do you have other physical conditions which cause pain (shoulder, inflammation etc.)? 
 No  Yes   
If yes, please describe:___________________________________________

Fitness Goals:
What are your goals for the next three months?

Have you had your body fat tested?	
If yes, what percentage:
Method of testing (calipers, hydrostatic, DEXA, etc.):
	
Describe your current training routine

Do you have specific fitness goals?	
If yes, please describe:

Are you training for a specific event?
If so, which one:	

On a scale of 1 to 10, rate your current fitness level (10 being the highest fitness level):  

PLEASE NOTE:  It is wise to seek your doctor’s advice before beginning any health/fitness/nutrition program!

Please read and initial the following:

__I have read and understand the refund policy.  
__I have read and understand the make-up day/sick day policy.
__If I am a new recruit, I know I must attend an orientation prior to the start of the first class.
__I understand that we will workout in the rain. In case of thunderstorm or downpour, class will be rescheduled.
__I will do my best to come to every class on time ready to workout.
__I will encourage fellow participants, be positive, and give my instructor the attention required to receive necessary instruction.

Acknowledgement and Assumption of Potential Risk

I understand and acknowledge: (a) that these activities, by their very nature, pose the potential risk of serious injury/illness to individuals who participate, (b) that in order to participate in these activities, I agree to assume liability and responsibility for any and all potential risks which may be associated with participation in such activities, (c) Core In Action Outdoor Fitness Bootcamp or Danielle Lien shall not be liable for any injury/illness suffered by me which is incident to and/or associated with preparing for and/or participating in the activity(ies), (d) that photos and/or videos of me participating in these activities may be taken for the sole purpose of assisting in the instruction and/or for the promotion of future programs.  I have no known medical condition which may pose a risk to the health and safety of me or others by participating in the activity (es).

Participants Signature_______________________Date_________________