MEDICAL HISTORY
If you are returning and have no medical changes, the medical section below does not need to be completed. All agreements remain the same.
NOTICE: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition program!
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
Medications:
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
Medications:
3. Do you have a seizure disorder (epilepsy)?
4. Do you have diabetes adult or juvenile?
Medications:
5. Have you ever been found to be anemic (low blood count)?
6. Do you have high blood pressure (hypertension)?
Medications:
7. Do you have or have you ever had the following diseases?
Heart Disease
Lung Disease
Kidney Disease
Liver Disease
8. Do you have asthma?
Medications:
9. Have you ever had a severe neck injury?
Describe:
10. Have you ever been knocked out?
Describe:
11. Do you wear glasses or contact lenses?
12. Have you had a broken bone or fracture in the past 2 years?
Describe:
13. Have you ever injured your back?
Describe:
14. Do you have back pain?
Never
Seldom
Occasionally
Frequently, with vigorous exercise or heavy lifting
15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?
Describe:
16. Do you have other physical conditions which cause pain?
Describe:
17. Detail any surgical procedures
18. If you have had your body fat tested, what is you percent body fat?
