Physical Activity Readiness Question

First name

Last name

Email

Phone

Birthday

Emergency contact information

First name

Second name

Phone

General health history

Have you been diagnosed with any medical conditions? (e.g., heart disease, diabetes, asthma, epilepsy, etc.) If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Are you currently taking any medications that may affect your ability to participate in physical activity? If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Have you ever had any surgery or major injuries that may affect your ability to participate in physical activity? If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Do you have any allergies? Please specify

Yes

No

Allergies

Physical activity history

Are you currently engaging in regular physical activity? (e.g., exercise, sports, dance, etc.)If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Have you ever participated in pole dance, exotic dance, or aerial dance before?If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Pregnancy

Are you currently pregnant? If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Risk factors

Do you experience chest pain or discomfort during physical activity? If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Have you experienced dizziness, fainting, or blackouts during physical activity? If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Are you currently under the influence of alcohol, drugs, or any substances that may impair your coordination or judgment? If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Do you have any joint or bone problems that may be aggravated by physical activity? If you answered yes, please provide details at the additional info section at the bottom of this form.

Yes

No

Please specify anything you think we should know about that was not covered above.

I declare that the info I’ve provided is accurate & complete

I accept terms and conditions and have read the privacy policy.

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

Initials