Fitness Health Assessment Form
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4FITNESS HEALTH ASSESSMENT FORM
Name:___________________________
Gender:
M
F
Date of Birth:________________
Street Address: __________________________________________________________________________
City:________________________________ State:_________________________ Zip:________________
Home Phone: (______)______________________ Cell/Work Phone:(________)_______________________
In case of emergency, contact:
Name:_________________________________________________________________________________
Home Phone: (_______)______________________ Cell Phone: (_______)__________________________
HEALTH HISTORY
PLEASE FILL OUT COMPLETELY ALL QUESTION BELOW. If you Answered YES to any
QUESTION BELOW,YOU NEED A WRITTEN MEDICAL RELASE FROM YOUR DOCTOR!!
Do you have or have you ever
Do you take any
had any of the following?
MEDICATIONS?
HEART
Heart Attack
YES
NO
For the Heart
YES
NO
Heart Disease
YES
NO
For High Blood Pressure
YES
NO
Stroke
YES
NO
High Cholesterol
YES
NO
Abnormal EKG
YES
NO
OTHER
Diabetes
YES
NO
IMPORTANT INFORMATION
Responding to this Health Questionnaire is purely voluntary and you do not have to share your responses with the staff of the Fitness
Services. However, please recognize that individuals with coronary risk factors or other medically significant risk factors, run a greater
chance of cardiovascular incident or increased risk of injury during physical activity. Although you are solely responsible for
determining if you are physically fit for any and all fitness activities, it is always advisable, especially if you are pregnant, suffer from an
underlying medical condition, take medication, smoke cigarettes, have a family history of coronary disease, or have recently suffered
an illness, injury or impairment, to consult a physician before undertaking any physical activity.
Please recognize the staff of the Fitness Services are not medical practitioners. However, any voluntary communication of the above
requested information to our staff may assist the staff in identifying adverse signs and symptoms that might compromise your well-
being and which should be evaluated and assessed by qualified medical personnel.
I HAVE READ AND UNDERSTAND THE PRECEDING STATEMENT
_______________________________________
____________________________
Signature Required
Date
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