Personal Training/medical Forms

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Personal Training/Medical Forms
1.
Medical Waiver/ Rules & Regulations
Name: _______________________________
Address: ______________________________________
City: _______________ State: _____Zip: ________ Phone: ________________
2. Medical Forms Personal Trainer- Medical Clearance
Medical History Questionnaire
Important factors to consider before undertaking any type of exercise program are as follows:
Are you on any medications? (Please list) __________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you smoke? ____ Yes ____ No
Do you have any physical problems that are of concern to you? ________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have any of the following:
Chest Pain? ___ Yes ___ No
Rheumatic Fever? ___ Yes ___ No
Coronary Heart Disease? ___ Yes ___ No
High Cholesterol? ___ Yes ___ No
Irregular Heartbeats? ___ Yes ___ No
Respiratory Problems? ___ Yes ___ No
High Blood Pressure? ___ Yes ___ No
Shortness of Breath? ___ Yes ___ No
Family History of Heart Disease? __ Yes __No
Chronic Cough? ___ Yes ___ No

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