3. Health-History Questionnaire
Full Name *
Your answer
Age *
Your answer
Sex *
Physician's Name *
Your answer
Physician's Phone Number *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Are you taking any medications, supplements, or drugs? *
If so, please list Medication, Dose, and Reason for Taking
Does your physician know you are participating in this exercise program? *
Describe any physical activity you do somewhat regularly *
Your answer
Do you now have, or have you had in the past:
If yes, click "Other" and explain
History of heart problems, chest pain, or stroke
Elevated blood pressure
Any chronic illness or condition
Difficulty with physical exercise
Advice from physician not to exercise
Recent surgery (last 12 months)
Pregnancy (now or within last 3 months)
History of breathing or lung problems
Muscle, joint, or back disorder, or any previous injury still affecting you
Diabetes or metabolic syndrome
Thyroid condition
Cigarette smoking habit
Obesity [Body Mass Index (BMI) > 30kg/m2]
Elevated blood cholesterol
History of heart problems in immediate family
Hernia, or any condition that may be aggravated by lifting weights or other physical activity
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