Health Screening FormPhysical activity has positive effects on the body e.g. improving body shape, making the heart stronger, relieving stress etc. If you haven’t participated in exercise for many years and have high cholesterol, sudden exercise could be fatal. So before undergoing regular physical activity please fill out this health screening form so I can see your capabilities and limitations.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeDate of Birth *Email Address *Phone Number * you Have condition? Has your doctor diagnosed a bone or joint problem, such as arthritis, that has been aggravated or made worse with exercise?* *YesNoDo you have high blood pressure? *YesNoDo you have low blood pressure? *YesNoDo you have Diabetes Mellitus or any other metabolic condition? *YesNoHas your doctor ever said that you have raised cholesterol (serum level 6.2 mmol/L)? *YesNoHave you ever been diagnosed with a heart condition and advised that you should only do physical activity recommended by your doctor? *YesNoHave you ever felt chest pain during physical activity? *YesNoIs your doctor prescribing you drugs or medication? *YesNoHave you ever suffered from shortness of breath at rest or with mild exertion? *YesNoIs there any history of Coronary Heart Disease in your family? *YesNoDo you feel faint, have spells of severe dizziness or have lost consciousness? *YesNoDo you smoke? *YesNoDo you know of any other reason why you should not participate in an exercise class? *YesNoIf you answered YES to any of the questions above or know of any reason not to participate in an exercise class, please leave details below:Signature Clear Signature Submit
