Health History

Please answer the following questions to the best of your ability. For the following questions, unless otherwise indicated, select the single best choice for each question. All of your responses are completely confidential.

First name

Last name

Height

Weight

1. Have you ever had a definite or suspected heart attack or stroke?

YesNo

2. Have you ever had coronary bypass surgery or any other type of heart surgery?

YesNo

3. Do you have any other cardiovascular or pulmonary (lung) disease (other than asthma, allergies, or mitral valve prolapse)?

YesNo

4. Do you have a history of any of the following? (select all that apply)

DiabetesThyroid issuesKidney issuesLiver disease

5. If you answered YES to any of Questions 1-4, please provide more details.

6. Do you currently have pain or discomfort in the chest or surrounding areas that occurs when you engage in physical activity?

YesNo

7. Do you currently have shortness of breath?

YesNo

8. Do you currently have unexplained dizziness or fainting?

YesNo

9. Do you currently have difficulty breathing at night except in an upright position?

YesNo

10. Do you currently have swelling of the ankles (recurrent and unrelated to injury)?

YesNo

11. Do you currently have heart palpitations (irregularity or racing of the heart on more than one occasion)?

YesNo

12. Do you currently have pain in the legs that causes you to stop walking?

YesNo

13. Do you currently have a known heart murmur?

YesNo

14. Are you pregnant or is it likely that you could be pregnant at this time?

YesNo

15. Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids?

YesNo

16. Do you currently smoke cigarettes or have quit within the past 6 months?

YesNo

17. Have you father or brother(s) had heart disease prior to age 55 OR mother or sister(s) had heart disease prior to age 65?

YesNo

18. Within the past 12 months, has a health professional told you that you have high blood pressure (systolic ≥ 140 OR diastolic ≥ 90)?

YesNo

19. Currently, do you have high blood pressure or within the past 12 months have you taken any medicines to control your blood pressure?

YesNo

20. If you answered YES to any of Questions 6-19, please provide more details.

21. Have you had surgery or been diagnosed with any disease in the past 3 months?

YesNo

22. If Yes, please list surgery(s) and date(s)

23. Are you currently under any treatment for any blood clots?

YesNo

24. Do you have problems with bones, joints, or muscles that may be aggravated with exercise?

YesNo

25. Do you have any back/neck problems?

YesNo

26. Have you been told by a health professional that you should not exercise?

YesNo

27. Are you currently being treated for any other medical condition by a doctor?

YesNo

28. During the past six months, have you experienced any unexplained weight loss or gain (greater than ten pounds for no known reason)?

YesNo

29. If you answered YES to any of Questions 23-28, please provide more details.

30. Please list below all prescription and over-the-counter medications you are currently taking.

31. Please list below all medicines that your physician has prescribed to you in the past 12 months which you are currently not taking.

I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in the development of my coaching program. I understand that certain medical or physical conditions which are known to me, but that I do not disclose to my coach may result in serious injury to me. If any of the above conditions change, I will immediately inform my coach of those changes. I, knowingly and willingly, assume all risks of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the attached questionnaire.

Entering your name in the above electronic signature indicates you acknowledge the information you have provided in the above form or waiver.