Fitness Health Record

• Site

• Name

• Conducted on

  Date

• Prepared by

• Location
  Address

• History of heart problems, murmurs, palpitations, chest pain, or stroke?

  No

  Yes

• High blood pressure?

  No

  Yes

• Any chronic illness or condition, such as diabetes, Multiple sclerosis (MS), or Parkinson's?

  No

  Yes

• Advice from a physician not to exercise?

  No

  Yes

• High blood cholesterol (specify how much)?

  No

  Yes

• History of heart problems in family (parents and siblings, list those with problems and age at onset

  No

  Yes

• Cigarette smoking habit (specify how many cigarettes a day)?

  No

  Yes

• History of breathing or lung problems (asthma)?

  No

  Yes

• Muscle, joint (arthritis), sciatica, low back disorder, or any previous injury still affecting you?

  No

  Yes

• Diabetes or thyroid condition?

  No

  Yes

• Pregnancy (now or within the last 12 months)?

  No

  Yes

• Obesity (over 20% of ideal weight)?

  No

  Yes

• Recent surgery (last 12 months)?

  No

  Yes

• Difficulty with exercise?

  No

  Yes

• Hernia or any other condition that may be aggravated by lifting weight?

  No

  Yes

• Dizziness or fainting spells

  No

  Yes

• Any physical limitation?

  No

  Yes

• Do you take any medications that will affect you when exercising

  No

  Yes

• Please specify

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• Prepared by

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