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Basic Info:
 

 

Name  

Address  
Home  Phone  
Work Phone  
Mobile Phone  
Email  

Basic Health History:
 

Sex:  

M F

Height:  

ft. in.

Current Weight:  

lbs.

Age:  

Current Weight:  

 

  
Doctor's Name:  
Doctor's Phone:  
Person to Contact in  Case of Emergency:  

Name

Phone

Are you taking any medications/drugs? If so, please list medication, dose and reason:

Does your doctor know you are participating in this exercise program?

Yes No

Check what applies to you (past or present): 
Increased blood pressure Pregnancy (now or within last 3 months) 
Any chronic illness or condition History of breathing or lung problems
Difficulty with physical exercise

Muscle, joint or back disorder, or any previous injury still affecting you

Advice from physician not to exercise Diabetes or thyroid condition
Recent surgery (last 12 months) Obesity (more than 20  percent over ideal body weight)
History of heart problems in immediate family Increased blood cholesterol
History of dizziness, blackouts or balance problems
Hernia, or any condition that may be aggravated by lifting weights
If you checked anything above, or if you have any other health issues, please explain:

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