Name *

First Name

Last Name

Phone

(###)

###

####

Do you have present medical problems *

Yes

No

Have you had any major illnesses in the past? *

Yes

No

Have you had surgery or hospitalization in the past? *

Yes

No

Are you currently taking any medications, vitamins or herbal supplements? *

Yes

No

Do you have a personal physician? *

Yes

No

HIGH BLOOD PRESSURE? *

140/90 OR HIGHER

YES

NO

HIGH CHOLESTEROL? *

LEVELS 240MG+

YES

NO

ABNORMAL EKG? *

YES

NO

FAMILY HISTORY *

HEART DISEASE, STROKE, OR CHEST PAIN IN PARENTS OR SIBLINGS BEFORE THE AGE OF 55

YES

NO

CHEST PAIN *

YES

NO

RAPID OR IRREGULAR HEART BEAT *

ARRHYTHMIA

YES

NO

SEIZER DISORDERS *

YES

NO

DIABETES? *

YES

NO

THROMBOSIS/EMBOLISM *

BLOOD CLOTS IN THE WEINS OR ARTERIES

YES

NO

HEART DISEASE *

YES

NO

HEART ATTACK *

YES

NO

HEART MURMERS *

YES

NO

SHORTNESS OF BREATH *

YES

NO

RESPIRATORY DISEASE *

YES

NO

HAVE YOU EXPERIENCED PAIN IN THE LEFT JAW OR NECK *

YES

NO

HAVE YOU EXPERIENCED FAINTING OR DIZINESS? *

YES

NO

DO YOU SMOKE CIGARETTES? *

SPECIFY THE FOLLOWING DETAILS BELOW

YES

NO

FOR FEMALE *

ARE YOU NOW, OR HAVE YOU BEEN PREGNANT IN THE LAS YEAR?

YES

NO

DO YOU EXERCISE ON A REGULAR BASIS? *

NONE

LIGHT

MODERATE

HEAVY

HAS A HEALTH PROFESSIONAL EVER RECOMMENDED THAT YOU RESTRICT ACTIVITY FOR ANY REASON? *

YES

NO

WHAT LEVEL OF ACTIVITY DOES YOUR JOB REQUIRE? *

LOW

MODERATE

HIGH

I AGREE