If you checked any of the above statements, consult your physician or other appropriate health care provider before engaging in exercise. You may need to use a facility with a medically qualified staff. Please indicate whether you have been cleared, are in the process of being cleared, or have not been cleared for exercise. *

Please select the statement that best applies to you:

Cardiovascular Risk Factors

You are a man older than 45 years of age.

You are a woman older than 55 years of age, have had a hysterectomy, or are postmenopausal.

You smoke, or quit smoking within the previous 6 months.

Your blood pressure is > 140/90 mmHg.

You do not know your blood pressure.

You take blood pressure medication.

Your blood cholesterol level is > 200 mg/dl.

You do not know your cholesterol level.

You have a close blood relative who had a heart attack or heart surgery before age 55 (father or mother) or age 65 (mother or sister).

You are physically inactive (i.e., you get <30 minutes of physical activity on at least 3 days per week.)

You are >20 pounds overweight.

If you marked two or more of the statements in the above section you should consult your physician or other appropriate health care provider before engaging in exercise. You might benefit from using a facility with a professionally qualified exercise staff to guide your exercise program. *

Please select the statement that best applies to you:

Please mark the checkbox below to certify that the above information is correct to the best of your knowledge. *

I have answered all questions above truthfully and to the best of my knowledge regarding my current health status.

Signature *

Date *

YYYY

Thank you for submitting the Medical History Form!

This information is crucial for your trainer to have so that they can create a fitness and wellness program that is suited to your needs. If you marked one of the items in the “History” section or more than two items in the “Cardiovascular Risk Factors” section, please see your physician and have them complete the Physician’s Clearance Form before beginning your exercise program.

Physician's Clearance

If you marked any of the items under the "History" section of the form, or more than two items under the "Cardiovascular Risk Factors" section of the form, please see your physician and have him/her complete the Physician's Clearance Form. Return this form to Jayd Harrison prior to the start of your training program.

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