Health History Name First Last Date MM slash DD slash YYYY For most people, physical activity should not pose any problem or hazard. The following questions aredesigned to identify the small number of adults for whom physical activity might be inappropriate or thosewho should have medical advice concerning the type of activity most suitable for them.Common sense is your best guide in answering these questions. Please read them carefully and checkthe “Yes” or “No” response opposite the question if it applies to you.Has your doctor ever said you have heart trouble?* Yes No If yes, please describe the problem and state when it was diagnosed.Do you often feel faint or have spells of severe dizziness?* Yes No Has a doctor ever told you that your blood pressure was too high?* Yes No Has your doctor ever told you that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse by exercise?* Yes No Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to do so?* Yes No Are you over age 65 and/or not accustomed to vigorous exercise?* Yes No Are you or have you ever been a diabetic?* Yes No Are you now pregnant, or have you been pregnant within the last 3 months?* Yes No Have you had any surgery in the last 3 months?* Yes No Have you been hospitalized in the last 2 years?* Yes No If so, when and why?Is your total serum cholesterol level over 240?* Yes No Have you ever smoked?* Yes No Do you have a family member who has had coronary disease before age 55?* Yes No Do you have pain or discomfort in your back?* Yes No Do you have pain or discomfort in your knee?* Yes No Which knee? Right Left Do you have pain or discomfort in your shoulder?* Yes No Which shoulder? Right Left Do you have pain or discomfort in your elbow?* Yes No Which elbow? Right Left Do you have pain or discomfort in your wrist?* Yes No Which wrist? Right Left Do you have pain or discomfort in your ankle?* Yes No Which ankle? Right Left Have you ever had a neck injury, such as whiplash?* Yes No When? Have you ever been treated for a spinal disk injury?* Yes No When? Have you experienced unaccustomed shortness of breath?* Yes No When was this first experienced? What treatment was used? Have you experienced dizziness?* Yes No When was this first experienced? What treatment was used? Have you experienced labored or uncomfortable breathing with or without pain?* Yes No When was this first experienced? What treatment was used? Have you experienced a heart murmur?* Yes No When was this first experienced? What treatment was used? I, , certify that I understand the foregoing questions and myanswers are true and complete. I also understand that this information is being provided as part of my initialassessment and may not be periodically updated.I, assume the risk for any changes in my medical conditionthat might affect my ability to exercise.Fill in your name, the date, and the first four digits of your social security number below to indicate your submission of this document:Name First Last Date MM slash DD slash YYYY Name First Last First four digits of your social security number:*
