Pre-Participation ScreeningPlease answer the following questions honestly and thoroughly. Your health and safety is my main priority. Open Form Pre-Participation Screening Name * First Name Last Name Email * Phone * (###) ### #### General Health Questions Has your doctor ever said that you have a heart condition or high blood pressure? * Yes No Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? * Yes No Are you currently taking prescribed medication for a chronic medical condition? Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure?) * Yes No Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? * Yes No Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? * Yes No Has your doctor ever said that you should only do medically supervised physical activity? * Yes No If you answered “yes” to any of the above questions, please provide more details below: Medical History Please list any known allergies * Please check the following disease conditions that you had or currently have: * Heart Attack Angina pectoris Peripheral vascular disease Stroke/transient ischemic attacks Abnormal heart rhythm Bronchitis Cancer Thyroid problems Rheumatic fever Eating disorder Heart surgery Pacemaker or defibrillator Diabetes Anemia Abnormal lung function Infectious mononucleosis Gout Asthma Osteoporosis Anxiety Heart valve problems Aneurysm High blood pressure High blood cholesterol High blood trigylcerides Emphysema Hernia Epilepsy or seizures Depression None Have you experienced, or do you currently experience, any of the following on a recurring basis? * Discomfort in the chest, jaw, neck, or arms Dizziness, lightheadedness, fainting Temporary blurring of vision Transient numbness or tingling in arm or leg Shortness of breath Rapid or skipped heart beats or palpitations Leg pain (cramping) Temporary blurring of vision If "yes" to any of the following provide details and indicate if the symptoms occur at rest, during exertion, or both. Have you experienced a major injury or had surgery that could affect your ability to exercise? * Please list any additional information that is essential to beginning an exercise and nutrition program. By checking the box below I agree that all information is accurate. * I agree By signing my name below I agree that all information is accurate. * Today's Date * MM DD YYYY Thank you!
