Assessment Application

ICS ATL advises you to consult your physician prior to increasing your physical activity

or starting any new exercise program

Athletic Readiness

Please answer each question. Use the text box to provide additional information where applicable.

Have you been diagnosed with high cholesterol or high blood pressure?

Yes

Have you been diagnosed with a heart condition or do you frequently experience chest pain?

Yes

Have you been dignosed with joint/bone disease?

Yes

Have you had any surgeries in the past 6 months?

Yes

Are you pregnant?

Yes

Are you currently taking any prescription medications?

Yes

Do you smoke?

Yes

If yes, how many packs/ singles per day?

Do you drink alcohol?

Yes

If yes, how many drinks per week on average?

Is there any reason you should not participate in an athletic Strength & Conditioning program?

Please list surgeries, all medications and/or provide any other information you would like ICS ATL to know relative to your current overall state of health.

Type and submit your e-signature below to confirm you have completed this form prior to starting a Strength & Conditioning Program with Anybodys Athlete LLC. or Coach “Butch” Wesley and that your responses are honest, true, and accurate.

You will be directed the to review & acknowledge Policies & Procedures upon submitting this form.

e-Signature Here

Inner City Strength ATL

Private Membership Trai Studio

innercitystrengthatl@gmail.com

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