Intake Form

Do you have any of the following? *

Heart problem or pacemaker Frequent pain in heart or chest Severe dizziness, blackouts or often feel faint High blood pressure Severe arthritis that might be made worse by exercise Heaviness, weakness or numbness in limbs None

Is there any reason not mentioned here why you may need to modify your exercise program? (For example: lung disease, diabetes) If YES - please state why: *

I hereby agree to participate in the Como Park/Falcon Heights Living at Home Block Nurse Exercise Program with the understanding that: I acknowledge upon starting the Como Park/Falcon Heights Living at Home Block Nurse Exercise Program that I am capable of participating in such a program or that as required, I have consulted with my physician concerning my level of activity during exercise routines. I recognize the risks of illness or injury inherent in such a program, and am participating in this program with the understanding that I hereby release and waive any and all claims against Como Park/Falcon Heights Living at Home Block Nurse Exercise Program from any injuries, claims, costs, damages, liabilities, or judgments arising out of my participation in Como Park/Falcon Heights Living at Home Block Nurse Exercise Program. This waiver shall remain in effect until withdrawn or revoked. I agree that if any of the information I listed above changes, I will inform of the changes.

By entering you name below you are signing this waiver.

Exercise Readiness and Demographics Form

Intake Form

Emergency Information:

Demographics:

Health Information:

Waiver and Release

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