JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Health & Medical
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Please enter your full name
*
Your answer
Emergency Contact Information:
*
Your answer
Date
*
MM
/
DD
/
YYYY
Does your physician approve of your participation in this exercise program?
*
Yes
No
Are you taking any medications that affect your vital signs (heart rate, blood pressure,breathing, etc.) or physical performance?
*
Yes
No
Are you a post-menopausal female?
*
Yes
No
Rate your current fitness level (1 = lowest, 10 = highest):
*
Your answer
Do you currently, or have you had in the past (please check all that apply)
*
History of heart problems in the immediate family
Cigarette, cigar, or pipe smoking habit
Increased blood pressure
Increased total blood cholesterol (>200 mg/dL)
Diabetes Mellitus
Asthma
Kidney Disease
Liver Disease
History of heart problems, chest pain, or stroke
History of breathing or lung problems
Muscle, joint, back disorder, or any previous injury still affecting you
Hernia or any condition that may be aggravated by lifting weights
Any chronic illness or condition
Obesity (more than 20% over ideal body weight)
Recent surgery (last 12 months)
Pregnancy (now or within the last year)
Difficulty with physical exercise
Advice from a physician not to exercise
None
Required
Other (please explain):
*
Yes
No
Please list all medications that you are currently taking:
*
Your answer
What would you like to accomplish during fitness classes?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Luke Infinger Organization.
Report Abuse
Forms
