Basic Information:

I understand the information on this form is essential to determine my medical health needs and the provision of
treatment. I understand that if any changes occur in my medical history/health, I will report it to DaRocha Fitness,
LLC as soon as possible. I have read and understand the above medical questionnaire. I acknowledge that all
answers have been recorded truthfully and will not hold Renato DaRocha, DaRocha Fitness, LLC or any staff
member responsible for any errors or omissions that I have made in the completion of this form.