Student Life » Gold Student Health & Wellness Center » Fitness Assessment Form Fitness Assessment Form If you have any questions with this form, or prefer direct contact, email [email protected] Name First Last Email Pitzer Affiliation(Required) Facutly Staff Student PhoneHeight Weight(Required)Age(Required)Health QuestionairePlease answer the followingHas your doctor ever said that you have a heart condition and should only perform physical activity recommended by a doctor?(Required) Yes No Do you feel pain in your chest when you perform physical activity?(Required) Yes No In the past month, have you had chest pain when you were not performing any physical activity?(Required) Yes No Do you lose balance because of dizziness or have you ever lost consciousness?(Required) Yes No Do you have bone or joint problems that could be worse by a change in your physical activity(Required) Yes No Is your doctor currently prescribing any medication for blood pressure or a heart condition?(Required) Yes No Do you know of any other reason wny you should not engage in physical activity?(Required) Yes No Agreement and ConcentConsent(Required) I agree to the privacy policy.Information provided by this form will only be used by Pitzer College Fitness Instructors and not shared with any additional entities or third parties for any purpose.
