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Personal Health and Fitness Medical History

Health History

Do you smoke?
Yes
No
Has your doctor ever said your blood pressure was too high or low?
Yes
No
Have you (or a family member) ever been told than you have diabetes
Yes
No
Do you have any cardiovascular problems (e.g, heart disease, previous heart attack, atherosclerosis, abnormal electrocardiogram)?
Yes
No
Has your doctor ever told you that your cholesterol level was high?
Yes
No
Are you overweight?
Yes
No
Do you have any injuries or orthopedic problems (e.g., bad back, bad knees, tendinitis, bursitis)?
Yes
No
Are you taking any prescribed medications or dietary supplements?
Yes
No
Are you pregnant or postpartum less than six weeks?
Yes
No
Do you have any other medical conditions or problems not previously mentioned?
Yes
No

Informed Consent

I acknowldge, to the best of my ability, that I am in good health and have no known medical problems that would restrict my ability to participate in this exercise program. I will immediately inform my trainer if my health condition should change.

Date
Month
Day
Year

Contact ME

406 Oak Street 

New London, WI 54961​

Tel: 920-359-0569

Healthymovements@att.net

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