Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Date of last medical physical exam *

MM

DD

YYYY

Do you have a family history of heart disease? *

Yes

No

Has a doctor ever said your blood pressure was too high or too low? *

Yes

No

Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)? *

Yes

No

Has your doctor ever told you that your cholesterol was too high? *

Yes

No

Do you have emphysema? * *

Yes

No

Do you have any metabolic diseases such as diabetes, hyperthyroidism, etc.? *

Yes

No

Do you have any injuries or orthopedic problems (back, knees, etc)? *

Yes

No

Have you had any surgery in the past year? *

Yes

No

Do you have stiff or swollen joints? *

Yes

No

Are you taking any prescribed medications or dietary supplementation? *

Yes

No

Are you pregnant or post-partum (< 6 weeks)? *

Yes

No

Do you, or have you ever suffered with anorexia or bulimia? *

Yes

No

Do you have any other medical condition, an injury that has caused you to stop running for a week or anything else we should be aware of that we have not mentioned? *

Yes

No

Are there any other physical or emotional problems that may affect your training? *

Yes

No

Do you drink alcohol? If so, how much per week? *

Yes

No

Do you, or have you ever, smoked regularly? *

Yes

No

Do you currently or have had any of the following conditions: heart disease, heart surgery, heart murmur, hypertension, thyroid problems, asthma, epilepsy, anaemia or stress fracture? *

Yes

No

Has your doctor ever said you have a heart condition and recommended medically supervised physical activity? *

Yes

No

Do you have chest pain brought on by physical activity? *

Yes

No

Have you developed chest pain within the last month? *

Yes

No

Do you lose consciousness or fall over as a result of dizziness? *

Yes

No

Do you have a bone or joint problem that could be aggravated by physical activity? *

Yes

No

Has a doctor ever recommended medication for high blood pressure or a heart condition? *

Yes

No

Are you aware of any reason your doctor would advise you against physical activity without medical supervision? *

Yes

No