Fitness Assessment Template & Personal Training Registration Packet Page 3
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7II. Health History Questionnaire
Assess your health status by marking all the true statements:
History
You have had:
_____a heart attack
_____heart surgery
_____cardiac catheterization
_____coronary angioplasty (PTCA)
_____pacemaker/implantable cardiac defibrillator/rhythm disturbance
_____heart valve disease
_____heart failure
_____heart transplantation
_____congenital heart disease
If you marked any of the
statements in this section,
Symptoms
approval from your physician or
_____You experience chest discomfort with exertion
other appropriate health care
_____You experience unreasonable breathlessness
provider is required before
_____You experience dizziness, fainting, or blackouts
engaging in our personal
_____You take heart medications
training program.
Other Health Issues
_____You have diabetes
_____You have asthma or other lung disease
_____You have burning or cramping sensation in your lower legs when walking
short distances
_____You have musculoskeletal problems that limit your physical activity
_____You have concerns about the safety of exercise
_____You take prescription medication(s)
_____You are pregnant
Cardiovascular Risk Factors
_____You are a man older than 45 years
_____You are a woman older than 55 years, have had a hysterectomy, or are
postmenopausal
_____You smoke, or quit smoking within the previous 6 months
If you marked two or more of
_____Your blood pressure is >140/90 mm Hg
the statements in this section
_____You do not know your blood pressure
approval is required from your
_____You take blood pressure medication
physician or other appropriate
_____Your blood cholesterol level is >200 mg/dL
health care provider before
_____You do not know your cholesterol level
engaging in our personal
_____You have a close relative who had a heart attack or heart surgery before
training program.
age 55 (father or brother) or age 65 (mother or sister)
_____You are physically inactive (i.e. you get <30 minutes of physical activity
on at least 3 days per week)
_____You are >20 pounds overweight
You should be able to exercise
_____None of the above
safely without consulting your
physician or other appropriate
health care provider.
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