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

High blood pressure?

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

Advice from a physician not to exercise?

High blood cholesterol (specify how much)?

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

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

History of breathing or lung problems (asthma)?

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

Diabetes or thyroid condition?

Pregnancy (now or within the last 12 months)?

Obesity (over 20% of ideal weight)?

Recent surgery (last 12 months)?

Difficulty with exercise?

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

Dizziness or fainting spells

Any physical limitation?

Do you take any medications that will affect you when exercising

Please specify

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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.