7. Do you currently have any of the following:
a. Pain or discomfort in the chest or surrounding areas that occurs when you engage in physical activity Y N
b. Shortness of breath Y N
c. Unexplained dizziness or fainting Y N
d. Difficulty breathing at night except in upright position Y N
e. Swelling of the ankles (recurrent and unrelated to injury) Y N
f. Heart palpitations (irregularity or racing of the heart on more then one occasion) Y N
g. Pain in the legs that causes you to stop walking (claudication) Y N
h. Known heart murmur Yes No
i. Have you discussed any of the above with your personal Physician?
8. Are you pregnant or is it likely that you could be pregnant at this time? If yes, what is your expected due date?
9. Have you had surgery or been diagnosed with any disease in the past 3 months? If yes, please list dateand surgery/disease
10. Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids?
11. Do you currently smoke cigarettes or have quit within the past 6 months?
12. 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?
13. Within the past 12 months, has a health professional told you that you have high blood pressure (systolic 140 OR diastolic 90)?
14. Currently, do you have high blood pressure or within the past 12 months, have you taken any medicines to control your blood pressure?
15. Have you ever been told by a health professional that you have a fasting blood glucose greater than or equal to 110 mg/dl?