| First Name: * |
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| Last Name: * |
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| E-mail Address: * |
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| Please answer only YES if the following questions apply to you below. Do you now, or have you had in the past?: |
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| 1. History of heart problems: |
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| 2. Increased blood pressure: |
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| 3. Any chronic illness or condition: |
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| 4. Difficulty with physical exercise: |
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| 5. Advice from a physician NOT to exercise: |
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| 6. Surgery within the last year: |
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| 7. Pregnancy (now or within last three months: |
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| 8. History of breathing or lung problems: |
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| 9. Muscle, joint, or back disorder: |
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| 10. Diabetes or thyroid condition: |
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| 11. Obesity (more than 20 percent over ideal body weight): |
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| 12. Increased blood cholesterol: |
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| 13. History of heart problems in immediate family: |
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| 14. Hernia or any condition that might be aggravated by lifting weights: |
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| Are you taking any medications including but not limited to beta blockers, diet pills or herbal supplements that may affect your heart rate or any other aspect of your performance and/or health in this fitness program?: * |
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| (INTITAL IN BOX) If you answered yes to one or more of these listed conditions, you may be at increased risk of potential complications during a rigorous exercise program and it advised to get a signed release from your physician to participate in rigorous activity.: * |
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| (INITIAL IN BOX) Remember, some form of exercise is almost always recommended, even in cases of increased risk. Exercise is known to help manage and ease conditions such as hypertension and diabetes. But in order to improve your quality of life, you need to make sure you’re not aggravating an existing medical condition or performing exercises that for you, may be contraindicated.: * |
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| (INITIAL IN BOX) I have answered this health history form truthfully and understand it is in my best interest to obtain a physician’s release if I am at increased risk.: * |
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