Medical History Form Page 2
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1
2High cholesterol?
Yes
No
Known heart disease?
Yes
No
Rheumatic heart disease?
Yes
No
A heart murmur?
Yes
No
Chest pain with exertion?
Yes
No
Irregular heart beat or palpitations?
Yes
No
Lightheadedness or do you faint?
Yes
No
Unusual shortness of breath?
Yes
No
Cramping pains in legs or feet?
Yes
No
Emphysema?
Yes
No
Other metabolic disorders (thyroid, kidney, etc.)?
Yes
No
Epilepsy?
Yes
No
Asthma?
Yes
No
Back pain: upper, middle, lower?
Yes
No
Other joint pain (explain on back of form)?
Yes
No
Muscle pain or an injury (explain on back of Form)?
Yes
No
To the best of my knowledge, the above information is true.
Signature ____________________________
Date____________________________
Witness ____________________________
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