First Name
Last Name
Date of birth
Height
Weight
Primary Phone Number
E-Mail
Emergency Contact Name
Emergency Contact Number
Medical / Surgical / Family / Hospitalization History
Do you have any allergies?
Do you take any medications?
Do you smoke?YesNo
Do you drink?NoRareModerateHeavy
When was your last physical exam?
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.
