Carolyn Appel

Name *

First Name

Last Name

Phone

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Movement Competency *

I am very comfortable performing fundamental movement patterns, such as squats, deadlifts, rows, presses, and planks.

Please rate your level of agreement with the statement:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Pregnancy *

Is there any chance that you are pregnant?

No

Yes

Has your doctor ever said that you have a heart condition and that you should only perform activity recommended by a doctor? *

No

Yes

Do you feel pain in your chest when you perform physical activity? *

No

Yes

In the past month, have you had chest pain when you were not performing any physical activity? *

No

Yes

Do you lose your balance because of dizziness or do you ever lose consciousness? *

No

Yes

Do you have a bone or joint problem that could be made worse by a chance in your physical activity? *

No

Yes

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

No

Yes

Do you know of any other reason why you should not engage in physical activity? *

No

Yes

Verification *

Please check the box below to indicate that, to the best of your knowledge, you have answered the questions truthfully and in sufficient detail to alert me of any medical considerations that may impact our work together.

Yes