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.
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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?

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


Heart attack
Heart operation
Congenital heart disease
High blood pressure
High cholesterol
Diabetes
Other major illness


Activity History



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?









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