1. Have you ever had a definite or suspected heart attack or stroke?
2. Have you ever had coronary bypass surgery or any other type of heart surgery?
3. Do you have any other cardiovascular or pulmonary (lung) disease (other than asthma, allergies, or mitral valve prolapse)?
4. Do you have a history of any of the following? (select all that apply)
Diabetes Thyroid issues Kidney issues Liver disease
5. If you answered YES to any of Questions 1-4, please provide more details.
6. Do you currently have pain or discomfort in the chest or surrounding areas that occurs when you engage in physical activity?
7. Do you currently have shortness of breath?
8. Do you currently have unexplained dizziness or fainting?
9. Do you currently have difficulty breathing at night except in an upright position?
10. Do you currently have swelling of the ankles (recurrent and unrelated to injury)?
11. Do you currently have heart palpitations (irregularity or racing of the heart on more than one occasion)?
12. Do you currently have pain in the legs that causes you to stop walking?
13. Do you currently have a known heart murmur?
14. Are you pregnant or is it likely that you could be pregnant at this time?
15. Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids?
16. Do you currently smoke cigarettes or have quit within the past 6 months?
17. Have you father or brother(s) had heart disease prior to age 55 OR mother or sister(s) had heart disease prior to age 65?
18. Within the past 12 months, has a health professional told you that you have high blood pressure (systolic ≥ 140 OR diastolic ≥ 90)?
19. Currently, do you have high blood pressure or within the past 12 months have you taken any medicines to control your blood pressure?
20. If you answered YES to any of Questions 6-19, please provide more details.
21. Have you had surgery or been diagnosed with any disease in the past 3 months?
22. If Yes, please list surgery(s) and date(s)
23. Are you currently under any treatment for any blood clots?
24. Do you have problems with bones, joints, or muscles that may be aggravated with exercise?
25. Do you have any back/neck problems?
26. Have you been told by a health professional that you should not exercise?
27. Are you currently being treated for any other medical condition by a doctor?
28. During the past six months, have you experienced any unexplained weight loss or gain (greater than ten pounds for no known reason)?
29. If you answered YES to any of Questions 23-28, please provide more details.
30. Please list below all prescription and over-the-counter medications you are currently taking.
31. Please list below all medicines that your physician has prescribed to you in the past 12 months which you are currently not taking.
Waiver
I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in the development of my coaching program. I understand that certain medical or physical conditions which are known to me, but that I do not disclose to my coach may result in serious injury to me. If any of the above conditions change, I will immediately inform my coach of those changes. I, knowingly and willingly, assume all risks of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the attached questionnaire.
Entering your name in the above electronic signature indicates you acknowledge the information you have provided in the above form or waiver.