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Medical History for Exercise Participation Revised 7/3/2018 Participant Information Please complete the following questions as accurately as you can. Update as necessary. This information is kept confidential and available to the program and emergency personnel only in the event an emergency. Participant’s Name: DOB: Gender: Phone Number: ( ) - Email: Emergency Contact: ( ) - Name Phone 1. Are you currently taking any medication? a. If yes, indicate what medication(s): 2. Do you smoke cigarettes or use tobacco products? a. If yes, indicate how long and how much? 3. Are you taking any supplements (vitamins, amino acids, herbs etc)? a. If yes, indicate what you are taking. 4. Have you ever suffered from any of the following? _____Heart attack _____Coronary artery disease _____Stroke _____Congestive heart failure _____Arthritis _____Cancer _____Allergies (if yes, include specifics): 5. Have you ever been diagnosed for any of the following? (Check if yes) _____Diabetes Mellitus _____Kidney problems _____Pregnancy _____Abnormal heart rate; murmur _____Hypertension _____Obesity _____Chronic Infectious Diseases _____Asthma _____Anemia _____Lower Back Pain _____Joint problems _____Dizziness _____Abnormal metabolism _____High Blood Cholesterol _____Fainting _____Muscle/skeletal problems _____Other (Please explain): ---PAGE BREAK--- Medical History for Exercise Participation Revised 7/3/2018 6. Is there a family history (parents, siblings) of the following before age 55? Heart disease _____Diabetes Obesity 7. Do you experience any of the following when you exercise? Pain or discomfort in the chest region _____Shortness of breath _____Dizziness or fainting _____Skipped heart beats pains 8. Is there any reason that you should not exercise? 9. Describe your current exercise program. 10. Do you have any muscle or skeletal problems or injuries? If yes, please describe. 11. Have you had any lower back pain which lasted more than one week? 12. Are you/could you be currently pregnant? Participant Authorization I understand the provided information and guarantee this form was completed correctly to the best of my knowledge. I understand that it is my responsibility to inform the instructor of any changes to the information I have provided. This information is kept confidential and available to the program and emergency personnel only in the event an emergency. However, the information obtained could be used for statistical or research purposes, though no association with my identity will be revealed. Participant Signature (or parent/guardian of minor participant) Date