Boston Marathon Sign-Up

Name

Email

Phone Number

Is this your first time running a marathon?
 Yes No

Are you a Fitcorp member?
 Yes No

If you are running for a charity, please select which one:
 Liver BWH BMC ACS Team Melanoma MS Tedy’s Team Mass Eye and Ear Other

If other, please specify:

Marathon Training Health History Questionnaire (HHQ)

Before you begin an exercise program at Fitcorp, please carefully read the following questions and answer them honestly. If you are less than 70 years old, this HHQ will indicate if it is advisable for you to check with your doctor before you start exercising. If you are 70 or more years old, checking with your doctor is advisable regardless of your responses to the questions.

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
 Yes No

2. Do you feel pain in your chest when you do physical activity?
 Yes No

3. In the past month, have you had chest pain when you were not doing physical activity?
 Yes No

4. Do you lose balance because of dizziness or do you ever lose consciousness?
 Yes No

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
 Yes No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
 Yes No

7. Do you know of any other reason why you should not do physical activity?
 Yes No

Emergency Contact Name

Emergency Contact Phone

If you answered YES to one or more of these questions or are 70 or more years old, we advise you to check with your doctor BEFORE starting an exercise program. We also advise you to contact your doctor if you experience any health changes that would cause you to change your answer to YES for any of the above questions

I have read, understood, and completed this HHQ and any questions that I had regarding this HHQ were answered to my full satisfaction.
 Yes No