Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Personal Physician

First Name

Last Name

Personal Physician Phone

(###)

###

####

Have you ever had a definite or suspected heart attack or stroke?

Yes

No

Have you ever had coronary bypass surgery or any other type of heart surgery?

Yes

No

Do you have any other cardiovascular or pulmonary (lung) disease (other than asthma, allergies, or mitral valve prolapse)?

Yes

No

Do you have a history of:

Diabetes

Thyroid disease

Kidney disease

Liver disease

Have you ever been told by a health professional that you have had an abnormal resting or exercise (treadmill) electrocardiogram (EKG)?

Yes

No

Pain or discomfort in the chest or surrounding areas that occurs when you engage in physical activity

Yes

No

Shortness of breath

Yes

No

Unexplained dizziness or fainting

Yes

No

Difficulty breathing at night except in upright position

Yes

No

Swelling of the ankles (recurrent and unrelated to injury)

Yes

No

Heart palpitations (irregularity or racing of the heart on more then one occasion)

Yes

No

Pain in the legs that causes you to stop walking (claudication)

Yes

No

Have you discussed any of the above with your personal Physician?

Yes

No

Are you pregnant or is it likely that you could be pregnant at this time?

Yes

No

Have you had surgery or been diagnosed with any disease in the past 3 months?

Yes

No

Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids?

Yes

No

Do you currently smoke cigarettes or have quit within the past 6 months?

Yes

No

Have you father or brother(s) had heart disease prior to age 55 OR mother or sister(s) had heart disease prior to age 65?

Yes

No

Within the past 12 months, has a health professional told you that you have high blood pressure (systolic ≥ 140 OR diastolic ≥ 90)?

Yes

No

Currently, do you have high blood pressure or within the past 12 months, have you taken any medicines to control your blood pressure?

Yes

No

Have you ever been told by a health professional that you have a fasting blood glucose greater than or equal to 110 mg/dl?

Yes

No

Are you currently under any treatment for any blood clots?

Yes

No

Do you have problems with bones, joints, or muscles that may be aggravated with exercise?

Yes

No

Do you have any back/neck problems?

Yes

No

Have you been told by a health professional that you should not exercise?

Yes

No

Are you currently being treated for any other medical condition by a physician?

Yes

No

Are there any other conditions (mitral valve prolapse, epilepsy, history of rheumatic fever, asthma, cancer, anemia, hepatitis, etc.) that may hinder your ability to exercise?

Yes

No

During the past six months, have you experienced any unexplained weight loss or gain (greater than ten pounds for no known reason)?

Yes

No

Are there any medicines that your physician has prescribed to you in the past 12 months which you are currently not taking?

Yes

No