Title Page

  • Site

  • Name

  • Conducted on

  • Prepared by

  • Location
  • 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

Sign Off

  • Prepared by

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.