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Step 1 - Register Personal & Health Information

The below information is required if you are new to Fitness Inspired or if you have any changes in your health, contact, or emergency information.

Is your health history and contact information already up to date with Fitness Inspired? If yes, then continue to Step 2: program selection

Thanks for choosing Fitness Inspired! Please fill out the required fields below.
* First Name
* Last Name
* Address
* City
* State
* Zipcode
* Phone Number
*E-Mail Address
Confirm E-Mail
* DOB (mm-dd-yyyy) Month Day Year
Height Feet Inches
Emergency Contact
Contact Name:
Contact Number 1:
Contact Number 2:
Relationship to You:
Physician's Information
Physician Name:
Physician Number:
Physician Address:
Health History
Please fill out the health questionnare below and check any health history, symptoms, or other issues that apply to you. You will need to fill this out for every FI program that you are registering.
History:
Heart Attack:

Yes No
Heart Surgery:

Yes No
Cardiac Catheterization:

Yes No
Coronary Angioplasty (PTCA):

Yes No
Rhythm Disturbance:

Yes No
Heart Failure / Heart Transplantation:

Yes No
Congenital Heart Disease:

Yes No
Symptoms:
Chest Discomfort with Exertion:

Yes No
Unreasonable Breathlessness:

Yes No
Dizziness, Fainting, or Blackouts:

Yes No
You Take Heart Medications:

Yes No
Other Health Issues:
Diabetes:

Yes No
Unreasonable Breathlessness:

Yes No
You have burning or cramping in your lower legs when walking short distances:

Yes No
Musculosceletal problems that limit your physical activity:

Yes No
Concerns about the safety of exercise:

Yes No
Take prescription medication(s):

Yes No
Pregnant:

Yes No
Cardiovascular Risk Factors:
You are a man older than 45 years:

Yes No
You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal:

Yes No
You smoke, or quit smoking within the previous 6 months:

Yes No
Your blood pressure is > 140/90:

Yes No
You do not know your blood pressure:

Yes No
You take blood pressure medication:

Yes No
Your blood cholesterol level is > 200 mg/dl:

Yes No
You do not know your blood cholesterol level:

Yes No
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister):

Yes No
You are physically inactive (i.e., you get less than 30 minutes of physical activity or at least 3 days per week):

Yes No
You are > 20 pounds overweight:

Yes No
Physician's Request

If you have marked ANY of the first 3 columns (history, symptoms, other health issues) you will need a physician clearance note to participate in any Fitness Inspired program.

If you have marked 2 or more of the Cardiovascular Risk Factors, then you will a need physician clearance note to participate in any Fitness Inspired program.
Download Physician's Request (100 KB)
Fitness Inspired Agreement and Waiver
Print fi® Agreement & Waiver
I agree & comply with the terms above
Security Check
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