Today's Date Name Address City State Zip Home Phone Cell Phone Work Phone Email Emergency Contact Name Emergency Contact Phone Age Physician Name Physician City Physician Phone Regular physical activity is safe for most people, however, some individuals should check with their doctor before they start an exercise program. To help me determine if you should consult with your doctor before starting to exercise, please read the following questions carefully and answer each one honestly. All information will be kept confidential. Please check YES or NO. Physician City Do you have a heart condition? Yes No Have you ever experienced a stroke? Yes No Do you have epilepsy? Yes No Are you pregnant? Yes No Do you have diabetes? Yes No Do you have emphysema? Yes No Do you feel pain in your chest when you engage in physical activity? Yes No In the past month, have you had chest pain when you were not doing physical activity? Yes No Do you have chronic bronchitis? Yes No Do you ever lose consciousness / lose your balance due to dizziness? Yes No Are you currently being treated for a bone or joint problem? Yes No Has a physician ever told you or are you aware that you have high blood pressure? Yes No Has anyone in your immediate family (parents/brothers/sisters) had a heart attack, stroke, or cardiovascular disease before age 55? Yes No Has a physician ever told you or are you aware that you have high cholesterol level? Yes No Do you currently smoke? Yes No Are you currently exercising LESS than 1 hour per week? Yes No Please list your activities. Can you get down and up from the floor unassisted? Yes No Are you currently taking any medications? Yes No Please list the medications you are taking and state their purpose. What are your specific fitness goals? Indicate all that apply. Increase strength and endurance Improve flexibility Improve cardiovascular fitness Improve muscle tone Reduce body fat Increase muscle mass Exercise regularly Injury Rehabilitation Sports conditioning Other Please specify What are your specific health goals? Indicate all that apply. Reduce stress Improve nutritional habits Control blood pressure Control cholesterol Stop smoking Achieve balance in life Improve productivity Reduce back pain Feel better overall Increase my health awareness Other Please specify I have read, understood, and completed this questionnaire. Name Date Cleared for exercise Yes No Untitled Submit Δ
