I have read, understood and completed this questionnaire. All questions were answered to my full satisfaction.

Medical History

Smoking (within the last year)	Yes  No
High Blood Pressure (> 140/90)	Yes  No
History of Heart Disease (personal)	Yes  No
History of Heart Disease (family)	Yes  No
Diabetes (personal)	Yes  No
Diabetes (family)	Yes  No
Elevated Cholesterol (> 240 mg/dl)	Yes  No
Heart Murmur	Yes  No
Arrhythmia	Yes  No
Pain or discomfort in chest	Yes  No

 

Have you ever had difficulty breathing?

Yes

 

No
If so, please explain:

 

Have you ever experienced fainting or dizzy spells?

Yes

 

No
If so, please explain:

 

Have you been injured recently?

Yes

 

No
If so, please explain:

 

Are you currently taking any medication?

Yes

 

No
If so, please explain:

 

Is there any condition that might limit your participation in an exercise program?

Yes

 

No
If so, please explain: