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Bodybinature LLC
Health Questionare
NATIONAL ACADEMY OF SPORTS MEDICINE
Client Name
Date
/
Month
/
Day
Year
Date
Age
Is your doctor currently prescribing any medication for your blood pressure or for a heart?
Yes
No
Do you know of any other reason why you should not engage in physical activity?
Yed
No
Do you have a bone or joint problem that could be made worse by a change in your physical state?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you perform physical activity?In the past month, have you had chest pain when you were not performing any physical activity?
Yes
No
Yes, to both
If you have answered YES to one or more of the above questions, consult your physicianbefore engaging in physical activity. Tell your physician which questions you answeredYES to. After medical evaluation, seek advice from your physician on what type ofactivity is suitable for your current condition.
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Do you partake in any recreational physical activities (golf, skiing, etc? (If YES, please explain during consultation.
Yes
No
Do you have any additional hobbies (reading, video games, etc.)? (If YES, please explain.)
Have you ever had any injuries or chronic pain? (If YES, please explain.)
Have you ever had any surgeries? (If YES, please explain.)
Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease,hypertension, high cholesterol, or diabetes?
Yes
No
Are you currently taking any medication? (If YES, please explain during consultation.
Yes
No
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