Health Form

 

Name__________________________________ Date ____________________Phone#_______________________

Age__________ Sex_____________ Address________________________________________________________

Emergency contact: Name / Phone#_________________________________________________________________

Are you taking any medications or drugs other than those prescribed by your physician? If so, list them / reason:

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Do you now, or have you had in the past:

1.  History of heart problems, chest pain or stroke                                                          Yes / No

2.  High cholesterol                                                                                                        Yes / No

3.  Increased blood pressure                                                                                          Yes / No

4.  Any chronic illness or condition                                                                                 Yes / No

5.  Difficulty with physical exercise                                                                                 Yes / No

6.  Advice from physician not to exercise                                                                       Yes / No

7.  Recent surgery ( last 12 months)                                                                               Yes / No

8.  Pregnancy ( now or with in last 3 months)                                                                  Yes / No  

9.  Muscle, joint or back disorder, or any previous injury still affecting you                      Yes / No

10.  History of breathing or lung problems                                                                      Yes / No

11.  Diabetes or thyroid condition                                                                                  Yes / No

12.  Smoke cigarettes                                                                                                    Yes / No

13.  Hernia, or any condition that may be aggravated by lifting weights and / or exercise  Yes / No

Please explain any "yes" answers / comments_____________________________________________________________

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