Spokane Aerial Performance Arts Health and Medical History Questionnaire

This information is used solely as an aid and will not be released without your knowledge and consent.
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
    2. Do you feel pain in your chest when you do physical activity?
    3. In the past month, have you had chest pain when you were not doing physical activity?
    4. Do you lose your balance because of dizziness or do you ever lose consciousness?
    5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by change in your physical activity?
    6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
    Please enter one response per row
    Rheumatic fever
    Recent operation
    Edema (swelling or ankles)
    High blood pressures
    Injury to back or knees
    Low blood pressure
    Seizures
    Lung disease
    Heart attack
    Fainting or dizziness
    Diabetes
    High cholesterol
    Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack) nocturnal dyspnea (shortness of breath at night)
    Shortness of breath at rest or with mild exertion
    Chest pains
    Palpitations or tachycardia (unusually strong or rapid heartbeat)
    Intermittent claudication (calf cramping)
    Pain, discomfort in the chest, neck, jaw, arms, or other areas
    Known heart murmur
    Unusual fatigue or shortness of breath with usual activities
    Temporary loss of visual acuity or speech, or short term numbness or weakness in one side, arm, or leg
    Other family history
    Please enter one response per row
    This is a required question
    Heart attack
    Heart operation
    Congenital heart disease
    High blood pressure
    High cholesterol
    Diabetes
    Other major illness
    Please enter one response per row
    This is a required question

    Activity History

    This is a required question
    Have you ever worked with a personal trainer before?
    Have you had a physical examination within the past 12 months?
    Do you participate in a regular exercise program at this time?
    Can you currently walk 4 miles briskly without fatigue?
    Can you currently do 2 pushups (not on knees)?
    Have you ever performed resistance training in the past?
    Do you have any injuries (bone or muscle disabilities) that may interfere with exercising?
    Do you smoke?
    Do you have a high amount of stress in your personal life?
    Are you employed?
    Do you consider your job to be high stress?
    Do you consider yourself overweight?
    Do you consider your overall diet healthy?
    Do you eat at restaurants more than once a week?
    Please enter one response per row
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question