Please answer the following questions to the best of your ability. For the following questions, unless otherwise indicated, circle the single best choice for each question. As is customary, all of your responses are completely confidential. If you have any physical handicaps or limitations that would require special assistance with this questionnaire, please let your trainer know. This form is in accordance with the American College of Sports Medicine guidelines for risk stratification when

followed correctly by your coach.

1. Have you ever had a definite or suspected heart attack or stroke?

Yes   No

2. Have you ever had coronary bypass surgery or any other type of heart surgery?  Yes  No

3. Do you have any other cardiovascular or pulmonary (lung) disease (other than asthma, allergies, or mitral valve prolapse)?  Yes   No

4. Do you have a history of: diabetes, thyroid, kidney, liver disease? (circle all that apply)

5. Have you ever been told by a health professional that you have had an abnormal resting or exercise (treadmill) electrocardiogram (EKG)?

Yes   No

 

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?

17. Are you currently under any treatment for any blood clots?

18. Do you have problems with bones, joints, or muscles that may be aggravated with exercise? Yes No

19. Do you have any back/neck problems?

20. Have you been told by a health professional that you should not exercise?

21. Are you currently being treated for any other medical condition by a physician?

22. Are there any other conditions (mitral valve prolapse, epilepsy, history of rheumatic fever, asthma, cancer, anemia, hepatitis, etc that may hinder your ability to exercise?Yes

23. During the past six months, have you experienced any unexplained weight loss or gain (greater than ten pounds for no known reason)?

25. Please list below all prescription and over-the-counter medications you are currently taking:

26. Are there any medicines that your physician has prescribed to you in the past 12 months which you

Ihave answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in the development of my coaching program.I understand that certain medical or physical conditions which are known to me, but that I do not disclose

to my coach may result in serious injury to me. If any of the above conditions change, I will immediately inform my coach of those changes. I, knowingly and willingly, assume all risks of injury resulting from my failure to disclose accurate, complete. and updated information in accordance with the attached questionnaire.