Ymca Personal Training Questionnaire Page 3
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15Family Health History
Please indicate if you have any primary relatives who have any of the following conditions. (check all that apply)
Asthma
Cancer
Hypertension
High Cholesterol
Arthritis
Diabetes
Heart Disease
Osteoporosis
Obesity
Stroke
Other:
Please provide a brief explanation for any of the above that have been checked.
Personal Health History
Please indicate if you have any of the following conditions. (check all that apply).
Asthma
Cancer
Hypertension
High Cholesterol
Arthritis
Diabetes
Heart Disease
Osteoporosis
Obesity
Stroke
Other:
Please provide a brief explanation for any of the above that have been checked.
Please indicate if you have had any joint injuries or surgeries that may limit or affect your ability to exercise.
Neck
Hip
Wrist/Hand
Shoulder
Knee
Ankle/Foot
Elbow
Low Back
Other
Please provide a brief explanation for any of the above that have been checked.
Please indicate any medications currently used.
Type of Medication
Purpose
Page 2
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