Registration Form
You may also download the Registration Form and the Medical Waiver here .
If you have answered YES to one or more questions on the Past Medical History Questionnaire you may download the Medical Consent form here .
Have you taken "Intake" in the past 90 days?
Yes, I have. here .)
Your Name*:
Your Email*:
Background:
School/Team:
Pro College Amateur Junior Other
Health and Lifestyle:
Please describe your current activity level (please be honest so that we can best tailor your program):Sedentary (desk job or inactive lifestyle, no exercise) Mild exercise (e.g., active lifestyle, climb stairs, walk 3 blocks, light golf) Occasional vigorous exercise (e.g., work or recreation, less than 4x per week for 30 minutes) Regular vigorous exercise (e.g., work or recreation 4x/week for 30 minutes or more)
What is your current occupation?
Average daily stress level:1 (Low) 2 3 4 5 6 7 8 9 10 (High)
ADDRESS:
PHONE:
PERSONAL INFORMATION:
DOB*:
—Please choose an option— Male Female
—Please choose an option— Single Married
EMERGENCY CONTACT INFORMATION
Name*:
OPTIONAL:
I would like to take part in positive promotional opportunities on my work and accomplishments with UpRight Movement.—Please choose an option— Yes No
Would you like to stay informed with the UpRight Movement email newsletter?—Please choose an option— Yes No
Past Medical History Form
Please answer the following questions.*
Yes No
If yes, please list your injuries (most recent first, with dates).
Athletic injury Work related injury Injury related to lifting Cause unknown Injury related to falling Motor vehicle accident Other
Yes No
If yes, please specify the date.
How would you rate your level of pain?1 (Low) 2 3 4 5 6 7 8 9 10 (High)
What activities/positions aggravate your condition?
Yes No
Name/Type of Practitioner Treatment Provided
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
If you answered YES to any of the items above, please briefly explain and give the date. Include any other pertinent information regarding your past medical history.
Yes No
If yes, please explain.
Yes No
If yes, please explain.
The above PAST MEDICAL HISTORY FORM questionnaire is meant to identify some obvious health problems that may limit your participation in exercise/or physical testing. Your acceptance into this program does not limit the possibility of undetected health problems. We urge you to see your physician regularly and to report any unusual symptoms you may encounter. You should report any unusual signs or symptoms that occur during exercise to your performance specialist and health professional.
You may be able to do any activity you want — as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those, which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
Find out which community programs are safe and helpful for you.
start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.
take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.
if you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better; or
if you are or may be pregnant – talk to your doctor before you start becoming more active.
Yes, I agree.
Signature*:
(for participants who are minors)
Signature:
here .
RELEASE AND WAIVER OF LIABILITY
Definitions
Terms and Provisions
Yes, I agree.
Signature*:
