Medical History Questionnaire

Please indicate in the space provided if you have a history of the following:
1. Heart attack   Yes   No   
2. Bypass or cardiac surgery   Yes    No   
3. Chest discomfort with exertion   Yes   No      
4. High blood pressure   Yes   No      
5. Rapid or runaway heartbeat   Yes   No      
6. Skipped heartbeat   Yes   No      
7. Rheumatic fever   Yes   No      
8. Phlebitis or embolism   Yes   No         
9. Shortness of breath w/ or with out/exercise   Yes   No   
10. Fainting or light-headedness   Yes   No      
11. Pulmonary disease or disorder   Yes   No      
12. High blood fat (lipid) level   Yes   No      
13. Stroke   Yes   No      
14. Recent hospitalization for any cause   Yes   No      

List specifics:
15. Orthopedic problems (including arthritis)   Yes   No      

1. List specifics: