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Health History
Please answer the following questions to the best of your ability. For the following questions, unless otherwise indicated, circle the single best choice for each question. As is customary, all of your responses are completely confidential and may only be used in group summaries and/or reports. All information collected is subject to the Privacy Act of 1974. If you have any physical handicaps or limitations that would require special assistance with this questionnaire, please let your trainer know. This form is in accordance with the American College of Sports Medicine guidelines for risk stratification when followed correctly by your trainer. Your trainer should be certified with a national organization in order to use these forms correctly.
Full Name *
Your answer
Height
Your answer
Weight
Your answer
Gender
Age
Your answer
Birthdate
MM
/
DD
/
YYYY
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Phone *
Your answer
Emergency Contact
Your answer
Emergency Contact Phone
Your answer
Personal Physician
Your answer
Personal Physician Phone
Your answer
Email *
Your answer
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