Athletic And Health History Athletic And Health HistoryName *FirstLastHas your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *YesNoDo you feel pain in your chest when you perform physical activity? *YesNoIn the past month, have you had chest pain when you were not performing physical activity? *YesNoDo you lose balance because of dizziness or do you ever lose consciousness? *YesNoDo you have a bone or joint problem that could be made worse by a change in your physical activity? *YesNoIs your doctor currently prescribing any medication for your blood pressure or for a heart condition? *YesNoDo you know of any other reason why you should not engage in physical activity? *YesNoIf you answered YES to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered YES to. After medical evaluation, seek advice from your physician as to what type of activity is suitable for your current condition. Current Height: *Current Weight: *Date Of Birth *What is your current resting heart rate?Do you take any drugs or medications? *YesNoPlease list any drugs or medications you are currently taking. If none, type none. *Date of your last medical physical: *Do you have a family history of heart disease? *YesNoDo you have emphysema? *YesNoAre you, or have you been, recently pregnant? *YesNoDo you have high cholesterol? *YesNoIf you have high cholesterol, are you under the care of a physician for it?YesNoHave you had surgery in the past year? *YesNoHave you ever had an injury that caused you to stop exercising for more than a week? *YesNoAre you, or have you ever been anorexic or bulimic? *YesNoAre there any other physical or emotional problems that may affect your training? *YesNoIf you answered yes to above question, please explain. Do you drink alcohol? *YesNoIf yes, how much per week?Do you, or have you ever smoked regularly? *YesNoDo you currently or have you had any of the following conditions? *Heart DiseaseHeart AttackHeart SurgeryHypertension (High Blood Pressure)Thyroid ProblemsAsthmaEpilepsyAnemiaStress FractureDiabetesHyperthyroidismNoneWebsiteSubmit
