The information obtained from this form will be used to assist in determining your health/physical condition in regarding your readiness for participation in a regular exercise program. It is important that each question be answered as completely and accurately as possible. All information recorded will be kept confidential.
The coronary heart disease risk factors have been assessed thoroughly according to the American College of Sports Medicine guidelines. Approval by a trainer is required prior to using the facility.
Name: _______________________ Date: __________
Age: _____ Sex: ______ Height: _____________ Weight: _______
Date of birth: ________ Home phone: ______________ Work phone: ____________
Cell phone: ____________________
Email address: _______________________
Emergency contact: ___________________ Phone: ___________________

MEDICAL HISTORY

Do you have any present medical or physical conditions which may limit your ability to participate in an exercise program? If so, please explain:

Are you taking any medications, vitamins, or supplements? If so, please list:
Do you have a personal physician? ____________________________
Date of last physical: ______________________


Have you ever been told you have :
High Blood Pressure ________ High Cholesterol ________
Abnormal EKG ________ Chest Pain ________
Rapid/Irregular Heart Beat ________ Seizure Disorders ________
Diabetes Mellitus ________ Thrombosis/Embolism ________
Heart Murmurs ________ Respiratory Disease ________
Shortness of Breath ________ Fainting/Dizziness ________

Do you have a family history of heart disease, stroke or chest pain before the age of 55? If so, please list relation and age of onset:
Do you smoke?___________ If yes, how many per day?_________________
How many years?___________________

If you quit, when? ________________
How many packs per day and for how long?______________________________
Are you now or have you been pregnant within the last year?__________
If so, date of delivery: ___________________

Do you consider yourself to be under stress?
If "Yes", circle amount and elaborate: ___ Mild ___ Moderate ___ Severe
EXERCISE HABITS

Are you currently exercising regularly? If "Yes", please elaborate:
How do you describe your job?
___ Sedentary ___ Moderately active ___ Very active ___ Physically demanding

Do you have any physical or health related issues that you feel might have an effect on you success in a regular exercise program? If "Yes", please explain:


What are your health and fitness goals?


I AGREE TO THE ABOVE INFORMATION AND KNOW IT IS CORRECT TO THE BEST OF MY KNOWLEDGE:


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Signature
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Date