Health History Inventory
Name
First Name
Last Name
Age
Sex
Please Select
Male
Female
Other
Prefer not to say
Name and number of your physician
Name and number of an emergency contact
Are you taking any medications, supplements, or drugs? If so, please list medication, dose, and reason
Does your physician know you are participating in this exercise program?
Describe any physical activity you do somewhat regularly.
Do you now have, or have you had in the past:
Rows
Yes
No
History of heart problems, chest pain, or stroke
Elevated blood pressure
Any chronic illness or condition
Difficulty with physical exercise
Advice from physician not to exercise
Recent surgery (last 12 months)
Pregnancy (now or within last 3 months)
History of breathing or lung problems
Muscle, joint, or back disorder, or any previous injury still affecting you
Diabetes or metabolic syndrome
Thyroid condition
Cigarette smoking habit
Obesity (body mass index (BMI) ≥ 30 kg/m^2)
Elevated blood cholesterol
History of heart problems in immediate family
Hernia, or any condition that may be aggravated by lifting weights or
other physical activity
Submit
Should be Empty: