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Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Has your doctor ever said you have heart trouble? *

Yes

No

Have you ever had angina pectoris, sharp pain, or heavy pressure in your chest as a result of exercise, walking, or other physical activity such as climbing stairs? *

(Note: This does not include the normal out of breath feeling that results from normal activity)

Yes

No

Do you experience any sharp pain or extreme tightness in your chest when you are hit with a cold blast of air? *

Yes

No

Have you ever experienced rapid heart action or palpitations? *

Yes

No

Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction, coronary insufficiency, or thrombosis? *

Yes

No

Have you ever had rheumatic fever? *

Yes

No

Do you have diabetes, hypertension, or high blood pressure? *

Yes

No

Does anyone in your family have diabetes, hypertension, or high blood pressure? *

Yes

No

Has more than one blood relative (parent, sibling, first cousin) had a heart attack or coronary artery disease before the age of 60? *

Yes

No

Have you ever taken medications or been on a special diet to lower your cholesterol? *

Yes

No

Have you ever taken digitalis, quinine, or any other drug for your heart? *

Yes

No

Have you ever taken nitroglycerine or any other tablets for chest pain—tablets you take by placing under the tongue? *

Yes

No

Are you overweight? *

Yes

No

Are you under a lot of stress? *

Yes

No

Do you drink excessively? *

Yes

No

Do you smoke cigarettes? *

Yes

No

Do you have a physical condition, impairment or disability, including a joint or muscle problem, that should be considered before you undertake an exercise program? *

Yes

No

Are you more than 65 years old? *

Yes

No

Are you more than 35 years old? *

Yes

No

Do you exercise fewer than three times per week? *

Yes

No

Name *

First Name

Last Name

Please indicate in the space provided if you have a history of the following: Heart Attack *

Yes

No

Bypass or cardiac surgery *

Yes

No

Chest discomfort with exertion *

Yes

No

High blood pressure *

Yes

No

Rapid or runaway heartbeat *

Yes

No

Skipped heartbeat *

Yes

No

Rheumatic fever *

Yes

No

Phlebitis or embolism *

Yes

No

Shortness of breath w/ or wo/ excercise *

Yes

No

Fainting or light-headedness *

Yes

No

Pulmonary disease or disorder *

Yes

No

High blood fat (lipid) level *

Yes

No

Stroke *

Yes

No

Recent hospitalization for any case *

Yes

No

Orthopedic problems *

Yes

No

Name *

First Name

Last Name

Are you currently involved in regular exercise program? *

Yes

No

Do you regularly walk or run 1 or more miles continuously? *

Yes

No

Do you practice weightlifting or calisthenics? *

Yes

No

Are you involved in an aerobic program? *

Yes

No

Do you frequently compete in competitive sports? *

Yes

No

Did you participate in high school or college athletics? *

Yes

No