Membership Introduction Form

Contact Information

First Name *

Last Name *

Email Address *

Phone *

Age *0 / 2

Are You a Veteran? *YesNo

What is your reason or goal for joining The Turn? *

Primary Health Condition *

Date of Diagnosis *

Month

Day

Year

An exact date is not required. Please estimate as best you can.

Additional Health Conditions

Have you experienced shortness of breath, chest discomfort or pain, rapid heartbeat with physical activity? *YesNo

Have you experienced any joint, bone, or muscle pain in the last 6 months? *YesNo

Have you experience any dizziness or loss of balance in the 12 months? *YesNo

Have you been hospitalized in the last 12 months? *YesNo

Have you had recent surgery? *YesNo

Are you currently in physical therapy? *YesNo

Do you use an assistive device or wheelchair? *YesNo

Do you know of any other reason why you should not do physical activity? *YesNo

Add any comments or information you wish to share with The Turn

If you are unable to complete this form online, you may call The Turn to answer these questions over the phone: 440-686-1074