Release & Waiver For Personal Fitness Training Program Page 3

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Health History Questionnaire
PERSONAL
Name: _____________________________________ Date: ____________________________
Address: ___________________________________ Date of Birth: ______________________
City: ____________________ State: _____________ Zip Code: ________________________
Home Phone: Work Phone:
Retired
Employed part time
Employed full time
MEDICAL HISTORY
Past History: Have you ever had past cardiovascular problems:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Family History (Including parents)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Present Symptoms: Do you experience...
High Blood Pressure Have any relatives ever had...
High Blood Pressure
Low Blood Pressure
High Blood Pressure
Heart Palpitations
High Cholesterol
Chest Pains
Congenital Heart Disease
Heart Attack
Heart Operations
Heart Murmur
Epilepsy
Stroke
Shortness of Breath
Lung Disease
Smoking
Osteoporosis
Arteriosclerosis
Diabetes Mellitus
Arthritis
Other Major Illness
Back Pain
Injuries to Back, Knees, Ankles
Swollen Legs
Varicose Veins
Operations
Sedentary
Other
Explain each checked
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

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