Date *

MM

DD

YYYY

Present/Past History

Have you had OR do you presently have any of the following conditions? (Check if yes.)

Rheumatic fever

Recent operation

Edema (swelling of ankles)

High blood pressure

Injury to back or knees

Low blood pressure

Seizures

Lung disease

Heart attack

Fainting or dizziness with or without physical exertion

Diabetes

High cholesterol

Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack)

Shortness of breath at rest or with mild exertion

Chest pains

Palpitations or tachycardia (unusually strong or rapid heartbeat)

Intermittent claudication (calf cramping)

Pain, discomfort in the chest, neck, jaw, arms, or other areas with or without physical exertion

Known heart murmur

Unusual fatigue or shortness of breath with usual activities

Temporary loss of visual acuity or speech, or short-term numbness or weakness in one side

Other

Family History

Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)

Heart arrhythmia

Heart attack

Heart operation

Congenital heart disease

Premature death before age 50

Significant disability secondary to a heart condition

Marfan syndrome

High blood pressure

High cholesterol

Diabetes

Other major illness

Are you presently employed? *

Yes

No

Have you ever worked with a Strength & Conditioning Specialist before? *

Yes

No

Do you participate in a regular exercise program at this time? *

Yes

No

Have you ever performed resistance training exercises in the past? *

Yes

No

Do you have injuries that may interfere with exercising? *

Yes

No

Do you smoke? *

Yes

No