Name:   

q    Male

q    Female

            Last                                                     First                                 M.I.       

Address:

City:                                                                    State:                                  Zip:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

E-Mail Address:

Social Security Number:

Date of Birth:

Emergency Contact Name:

Phone Number:

Primary Care Physician:

Phone Number:

A physician’s release will be required if you check any item below.

Yes

No

Has a doctor ever said that you have a heart condition and recommended only medically supervised activity?

Do you have chest pain brought on by physical activity?

Have you developed chest pain in the past month?

Have you on one or more occasions lost consciousness or fallen over as a result of dizziness?

Do you have a bone or joint problem that could be aggravated by the proposed physical activity?

Has a doctor ever recommended medication for your blood pressure or a heart condition?

Are you aware, through your own experience or a doctor’s advice, of any other physical reason that would prohibit you from exercising without medical supervision?

Medications

Yes

No

Overall Health

√ one

Describe

Blood pressure

Poor

Cholesterol

Fair

Blood Sugar

Good

Heart Meds

Excellent

Other Meds

Orthopedic problems

Please explain any answers marked yes above:

Coronary Artery Disease Risk Factors (Please √ all that apply)

Has heart disease

Physical inactivity

Family history of heart disease

High HDL (negative risk factor)

High blood pressure

Never smoked

High cholesterol

Use to smoke

Diabetes

Still smoke