| 1. Do you have or has your physician told you that you have any muscle or joint problems such as painful or swollen joints, back pain, etc., which may prevent you from exercising or may be aggravated by exercise? |
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| 2. Do you have metabolic or neurological disorders such diabetes, stroke, etc., which may be aggravated by exercise? |
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| 3. Do you have unusual shortness of breath or difficulty breathing upon very mild exertion, or do you often feel faint or dizzy? |
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| 4. Do you often have chest pain or pain irradiating from your chest area? |
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| 5. Has your physician ever told you that you have a heart or vascular problem (high blood pressure, stroke, angina, heart attack, bypass surgery)? |
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| 6. Is there any physical reason why you should not engage in an exercise program? |
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| 7. Are you 65 years of age or older and not accustomed to moderately vigorous activity? |
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| 8. Are you taking any medications that may prevent you from exercising or may be aggravated by exercise? |
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| 9. FOR PREGNANT FEMALES ONLY: Is there any reason why you should not engage in exercise? Explain |
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| 10. Are you presently a smoker? |
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| If Yes, do you smoke |
| Cigarettes Pipe
Cigar
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Cardiovascular Disease:
Please list any of your relatives who have high blood pressure, have/had a heart attack, stroke or angina. Write down their relationship to you and the age at which they started having problems.
Please list: Relative, The problem, Age |
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12. Cholesterol Levels:
Have you had your cholesterol level tested? |
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| What is your Level? |
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| 13. What is your occupation?: |
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| 14. List any exercise you have been doing in the past 4 months. Please list the Exercise and Times per week |
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| Full Name:
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| Email:
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