Health-HistoryQuestionnaire Logo
  •  / /
  • Person to contact in case of emergency:

  • Do you now have, or have you had in the past:

    1. History of heart problems, chest pain, or stroke

    3. Any chronic illness or condition

    4. Difficulty with physical exercise

    5. Advice from physician not to exercise

    6. Recent surgery (last 12 months)

    7. Pregnancy (now or within last 3 months)

    8. History of breathing or lung problems

    9. Muscle, joint, or back disorder, or any previous injury still affecting you

    10. Diabetes or metabolic syndrome

    13. Obesity [body mass index (BMI) ≥30 kg/m2]

    14. Elevated blood cholesterol

    15. History of heart problems in immediate family

    16. Hernia, or any condition that may be aggravated by lifting weights or other physical activity

  • ©2014 AMERICAN COUNCIL ON EXERCISE

  •  
  • Should be Empty: