SHKUA
FITNESS
S
afety
H
ealth
K
nowledge
U
nderstanding
A
pplication
info
@shkuafit
ness
.com
Home
About Us
U.S. Obesity Stats
Services
S.W.A.T-IT
Sign Me Up
Registration
D.I.E.T
Contact Us
Register
After completing your personal health history, click
Sign Me Up
to choose your SWAT session package.
You should consult with your doctor before participating in any physical fitness program.
Personal Health History
*
Name:
*
Address:
*
City:
*
State/Province:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Québec
Saskatchewan
Yukon
*
Gender:
Male
Female
Height:
Weight:
*
Birth Date:
Mobile Phone:
Home Phone:
Email:
Contact Preference:
Phone
Email
Postal mail
Physician's name:
Physician's phone:
Emergency contact name and relationship:
Emergency contact phone:
*
Check all that apply:
History of heart problems, chest pain or stroke?
Increased blood cholesterol?
Hypertension?
Diabetes or thyroid condition?
Asthma?
Swollen, stiff, or painful joints?
Any form of cancer past or present?
Take prescription medication?
Take dietary or nutritional supplements?
Pregnancy (now or within the last 3 months)
Do you smoke?
Do you ever lose balance because of dizziness or ever lose consciousness?
Does your occupation or lifestyle involve extended periods of sitting?
Has your doctor recommended physical exercise?
Has your doctor recommended dietary changes?
*
Please list any medication and reasons for usage:
Please list any dietary and nutritional supplements and reason for usage:
Please list any surgeries:
List approximate age for each surgery
Are you involved in any sports or physical activities?:
List activities and how often
Submit Form:
Submit
Reset
info
@shkuafit
ness
.com