Health History Name First Last Date For most people, physical activity should not pose any problem or hazard. The following questions aredesigned to identify the small number of adults for whom physical activity might be inappropriate or thosewho should have medical advice concerning the type of activity most suitable for them.Common sense is your best guide in answering these questions. Please read them carefully and checkthe “Yes” or “No” response opposite the question if it applies to you.Has your doctor ever said you have heart trouble?*YesNoIf yes, please describe the problem and state when it was diagnosed.Do you often feel faint or have spells of severe dizziness?*YesNoHas a doctor ever told you that your blood pressure was too high?*YesNoHas your doctor ever told you that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse by exercise?*YesNoIs there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to do so?*YesNoAre you over age 65 and/or not accustomed to vigorous exercise?*YesNoAre you or have you ever been a diabetic?*YesNoAre you now pregnant, or have you been pregnant within the last 3 months?*YesNoHave you had any surgery in the last 3 months?*YesNoHave you been hospitalized in the last 2 years?*YesNoIf so, when and why?Is your total serum cholesterol level over 240?*YesNoHave you ever smoked?*YesNoDo you have a family member who has had coronary disease before age 55?*YesNoDo you have pain or discomfort in your back?*YesNoDo you have pain or discomfort in your knee?*YesNoWhich knee?RightLeftDo you have pain or discomfort in your shoulder?*YesNoWhich shoulder?RightLeftDo you have pain or discomfort in your elbow?*YesNoWhich elbow?RightLeftDo you have pain or discomfort in your wrist?*YesNoWhich wrist?RightLeftDo you have pain or discomfort in your ankle?*YesNoWhich ankle?RightLeftHave you ever had a neck injury, such as whiplash?*YesNoWhen?Have you ever been treated for a spinal disk injury?*YesNoWhen?Have you experienced unaccustomed shortness of breath?*YesNoWhen was this first experienced?What treatment was used?Have you experienced dizziness?*YesNoWhen was this first experienced?What treatment was used?Have you experienced labored or uncomfortable breathing with or without pain?*YesNoWhen was this first experienced?What treatment was used?Have you experienced a heart murmur?*YesNoWhen was this first experienced?What treatment was used?I, , certify that I understand the foregoing questions and myanswers are true and complete. I also understand that this information is being provided as part of my initialassessment and may not be periodically updated.I, assume the risk for any changes in my medical conditionthat might affect my ability to exercise.Fill in your name, the date, and the first four digits of your social security number below to indicate your submission of this document:Name First Last Date Name First Last First four digits of your social security number:* This iframe contains the logic required to handle Ajax powered Gravity Forms.