Health Screening Form
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2Tri-Community YMCA
HEALTH SCREENING FORM (WATER EXERCISE)
Name _____________________________________ Home Phone # ___________________ Date __________________
Male ____ Female ___
Age ______
DOB ______________ Height ___________ Weight _________
This form is intended to obtain information about your health that will assist the staff in helping you with your fitness
program. Please answer all questions to the best of your knowledge.
1. Cardio/Respiratory
Do you have any history of Cardio/Respiratory problems or pain? If so, please explain including any treatment
received. _______________________________________________________________________________________
_______________________________________________________________________________________________
2. Blood Pressure
Do you have high blood pressure?
Yes
No
Have you had high blood pressure in the past?
Yes
No
Are you on medication for high blood pressure?
Yes
No
_______ Don’t Know
3. Smoking
Do you smoke?
Yes
No
Are you a former smoker?
Yes
No
If yes, please give the date you quit __________________________________
4. Swimming
Are you a swimmer?
Yes
No
Are you comfortable in the deep end of the pool?
Yes
No
5. Diabetes/Edpilepsy
Have you ever been diagnosed with Diabetes or Epilepsy?
Yes
No
Are you currently taking medication? If so, please explain ________________________________________________
_______________________________________________________________________________________________
6. Heart Problems
Have you ever had a heart attack?
Yes
No
Have you had heart surgery?
Yes
No
Have you ever had a stroke?
Yes
No
Do you have angina?
Yes
No
Describe any treatment received: ____________________________________________________________________
_______________________________________________________________________________________________
7. Family History
Have any of your blood relatives had heart disease, heart surgery
or angina?
Yes
No
8
Orthopedic Problems
Do you have any serious orthopedic problems that would prevent you
from taking water fitness exercise classes
Yes
No
If yes, please explain
_______________________________________________________________________________________________
9. Medications
Are you currently taking any medications?
Yes
No
If yes, please explain ______________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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