Health History and Liability Form

Health History

Name:*

First Middle Last

Phone:*

Birth Date:*

Gender:*

Male
Female

Address:*

Street Address City State / Province / Region ZIP / Postal Code

Emergency Contact:*

Phone:*

Height:*

Weight:*

Age:*

Email:*

Regular physical activity is safe for most people. The American College of Sports Medicine (ACSM) standards indicate that some individuals should check with their doctor concerning their participation in an exercise program. To help us determine if you should consuit with your doctor, rean the following questions carefully and answer each one honestly. If you answer "YES" to any one of questions 1-12, or answer "YES" to 2 or more of questions 13-19, we will require your private physician's concurrence in order for you to participate in exercise programs at Shsrpa. All information will be kept confidential.

Please check Yes or No

1. Have you had/have a heart attack, heart surgery, cardiac catheterization, angioplasty, implanted cardiac device,rhythm disturbance, heart valve disease, heart failure, heart transplantation, congenital heart disease.*

Yes
No

Check Yes all that apply

2. Have you ever experienced a stroke?*

Yes
No

3. Do you have epilepsy?*

Yes
No

4. Are you pregnant?*

Yes
No

5. Do you have diabetes?*

Yes
No

6. Do you have emphysema?*

Yes
No

7. Have you had an asthma attack within the last two years or are you taking asthma madication?*

Yes
No

8. Do you feel pain in your chest when you engage in physical activity?*

Yes
No

9. Do you have choronic bronchitis?*

Yes
No

10. In past month, have you had chest pain when you were not doing physical activity?*

Yes
No

11. Do you ever lose consciousness or do you ever lose control of your balance due to chronic dizziness?*

Yes
No

12. Are you currently being treated for a musculo-sketstai problem that restricts you from engaging in physical activity?*

Yes
No

13. Has a physician ever told you or are you aware that you have high blood pressure or are you taking high blood pressure medication?*

Yes
No

14. Has anyone in your immadiate family (parants/brothers/sisters) had a heart attack, stroke or cardiovascular disease before age 55?*

Yes
No

15. Has a physician ever told you or are you aware that you have a high cholasterol level or are you taking cholesterol medication?*

Yes
No

16. Do you currently smoke?*

Yes
No

17. Are you a male over 44 years of age?*

Yes
No

18. Are you a female over 54 years of age?*

Yes
No

19. Are you currently exercising Less than 1 hour per week?*

Yes
No

If you answered no, please list your activities.

20. Are you currently taking medication?*

Yes
No

If you answered yes, please list the medications.

21. Orthopedic injury history/orthopedic surgery history

22. List any other condition and/or medication that would impair your ability to begin an exercise program

I have read, understand, and completed this questionnaire. Any questions that I had were answered in my full satisfaction. I understand I will complete an updated Health History Questionnaire if I have a known change in my health status

Signature:*

Date:*

Step 1 of 2

Health History

Please check Yes or No

WAIVER OF LIABILITY FOR GYM USE

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