Harris County Precinct One Adult Program Registration Form for

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Participant Information
Last Name: First:    Middle: 
Suffix: Race:          Gender: 
Date of Birth:    Home Phone:     Cell Phone: 
City: State:     Zip: 
Emergency Contact Information
  Name of person not residing with you:      Contact Phone: 
City:     State:      Zip:  
  Relationship to Applicant: 
Insurance/Doctor Information
 Do you have medical Insurance? Insurance Company:      
Medical Insurance Group #: Doctor's Name:
Medical Insurance Policy #: Doctor's Address:
Insurance Phone: Doctor's Phone:
Medical Condition Information
 Do you have conditions or limitations that could impede your participation in this program? 
 Please click on all the medical 
 conditions you have had 
Please list
all known allergies
 Have you ever had an
 exercise stress test? 
If yes, were the stress
 test results 
 Do you take any medications
 on a regular basis? 
If yes, please list the
medication(s) you are taking
 Have you ever been
If yes, please explain the
reason for hospitalization
Are you pregnant?    Do you smoke?    Are you moderately
   active most days of the week?
When was the last time
you had a physical exam?
 List any other conditions
 or limitations that may impede
 your participation in the program
Click here to read   Terms and conditions
* By clicking Submit, you agree to the terms and conditions of the disclaimer.