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Health History Form Sex M ( ) F ( ) Physician's Name Physician's Phone ( ) 1) Are you taking any medications or drugs? If so, please list medication, dose, and reason. 2) Does your physician ask you to inform him before participating in the exercise program? 3) Describe any physical activity you do somewhat regularly. 4) Answer the following health questionnaire in Yes or No YES NO History of heart problems, chest pain, or stroke High blood pressure Any chronic illness or condition History of heart problems in immediate family Hernia, or any condition that may be aggravated by lifting weights Recent surgery (last 12 months) Pregnancy (now or within last 3 months) History of breathing or lung problems Muscle, joint, or back disorder, or any previous injury still affecting you Diabetes or thyroid condition Cigarette smoking habit/status Obesity (more than 20% over ideal body weight) Increased blood cholesterol Please explain any "yes" answers on the blank space. (Comments) Comments: ---PAGE BREAK--- All the above information is true to my knowledge and I bond to inform the fitness center/instructor whenever there is change in my health status. Name of the Signature