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Medical History & Waiver for Melrose Boot Camp







  First Name*  
  Last Name*  
  Email*  
  Address*  
  City*  
  State*  
  Zip*  
  Phone*  
  Age*  
  Weight (lbs)*  
  Height *  
  Emergency Contact*  
  Emergency Phone Number*  
  Current Medications*  
  Medical Limitations*  
  Running Currently  
  Running HS or College  
  Sports Played in Past*  
  Current Sports, Workouts, Training*  
  Injuries, Pain, Surgery*  
  Heart Condition*  
yes
no
  High Blood Pressure*  
yes
no
  High Cholesterol*  
yes
no
  Stroke*  
yes
no
  Heart Attack*  
yes
no
  Chest Pain with Exercise*  
yes
no
  Chest Pain at Rest*  
yes
no
  Emphysema*  
yes
no
  Chronic Bronchitis*  
yes
no
  Diabetes*  
yes
no
  Pregnant*  
yes
no
  Smoker*  
yes
no
  Family Member Heart Attack*  
yes
no
  Please explain any ‘Yes’ answers above*  
  Reason why you can’t or shouldn’t participate*  
  Anything Else We Should Know*  
  How did you hear about us?*  
  Date*  
  Waiver Signature (I agree with the waiver below)*  
yes
no
 
Verification code*