| History: Have you had - | |
| A heart attack | |
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| Heart surgery | |
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| Cardiac catheterization | |
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| Coronary angioplasty (PTCA) | |
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| Pacemaker/implantable cardiac defibrillator | |
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| Heart valve disease | |
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| Heart failure | |
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| Heart transplant | |
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| Congenital heart disease | |
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Symptoms: Do you
Experience chest discomfort with exertion | |
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| Experience unreasonable breathlessness | |
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| Experience dizziness, fainting, blackouts | |
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| Take heart medications | |
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| Other health issues: Do you have | |
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| Diabetes | |
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| Asthma or other lung disease | |
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| Burning or cramping in your lower legs when walking short distances | |
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| Musculoskeletal problems that limit your physical activity | |
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| Concerns about the safety of exercise | |
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| Take prescription medication(s) | |
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| Are you pregnant | |
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| Cardiovascular Risk Factors* | |
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| Are you a man older than 45 years | |
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| Are you a woman older than 55 years, or you have had a hysterectomy, or you are postmenopausal | |
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| Do you smoke or have quit in the previous six months | |
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| Do you know your blood pressure | |
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| Is your blood pressure greater than 140/90 | |
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| Do you take blood pressure medication | |
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| Do you know your cholesterol level | |
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| Is you cholesterol level >200 mg/dL | |
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| Do you have a close blood relative who had a heart attack before age 55 (male) or age 65 (female) | |
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| Are you physically inactive (i.e., you get less than 30 min. of physical activity on at least 3 days per week) | |
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| Are you more than 20 pounds overweight | |
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| Do you know of any other physical condition or aliment that you have that would prevent you or hinder you from performing workouts or participating in cardio exercises. Please list any information that you think your trainer should know. | |
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| By initialing this box you indicate that you have answered the about questions truthfully and to the best of your ability. | |
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