| QUESTIONS: | |
| 1. Have you had a physical from your physician within the past year? | Y/N |
| 2. Has a physician ever advised you not to exercise? | Y/N |
| 3. Have you ever been given an exercise prescription by a physician? | Y/N |
| 4. Have you ever or do you have difficulty with physical exercise? | Y/N |
| 5. Is there a history of hear problems within your immediate family? | Y/N |
| 6. Do you have high blood pressure? | Y/N |
| 7. Do you have Diabetes? YES/NO If so, do you take insulin? | Y/N |
| 8. Have you ever had a history of respiratory or lung problems? | Y/N |
| 9. Are you currently on any medications
that directly affect the heart, lungs,
or circulatory system (i.e. Blood Pressure Medications)? |
Y/N |
| If yes, Please list: _______________________________________________________________ _______________________________________________________________ | |
| 10. Do have high blood cholesterol? | Y/N |
| Don't know | |
| 11. Do you have thyroid problem? | Y/N |
| 12. Do you have a chronic illness or condition? | Y/N |
| 13. Do you have a hernia, or
any condition that may be aggravated by lifting
weights? |
Y/N |
| 14. Do you have an infectious or communicable disease? | Y/N |
| 15. Have you had surgery within the past 12 month? | Y/N |
| 16. Do you have any muscle, joint,
back injury, or any previous injury still
affecting you? |
Y/N |
| 17. Are you currently pregnant or have been within the past 3 months? | Y/N |
| 18. If you have answered YES
to any of the above questions, please explain
below. Also please list any information that you feel we should know before setting you up on an exercise program: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ |
|
| 19. Person to be contacted in
case of an emergency ____________________
Phone: (H) ______________________ (W) _______________________ |
|
| 20. Physicians Name: _____________________
Phone: _________________
Address: ______________________________ |
|
|
Your Signature: ________________________ |