Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Care Physician *

First Name

Last Name

Physician Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

1. Have you ever been told by a doctor that you have or had heart problems, abnormal EKG, or had a heart attack/stroke? *

YES

NO

2. Have you ever had coronary by-pass surgery, angioplasty, or any other type of heart surgery? *

YES

NO

3. Have you ever had difficulty breathing or become short of breath with mild or light exertion? *

YES

NO

4. Do you have a history of diabetes or thyroid, kidney, or liver disease? *

YES

NO

5. Have you ever experienced irregular heartbeat (arrhythmia) or been diagnosed with a heart condition or disease? *

YES

NO

Name *

First Name

Last Name

a. Pain or discomfort in the chest or surrounding areas that occurs when you engage in exercise or physical activity? *

YES

NO

b. Shortness of breath with activity or at rest? *

YES

NO

c. Unexplained dizziness or fainting? *

YES

NO

d. Difficulty in the ankles or lower extremities (other than due to an injury)? *

YES

NO

e. Swelling in the ankles or lower extremities (other than due to injury)? *

YES

NO

f. Heart palpitations (rapid or irregular heartbeat)? *

YES

NO

g. Pain in the legs that may cause you to stop walking? *

YES

NO

h. Known heart murmur? *

YES

NO

8. Are you pregnant or is it likely that you may become pregnant at this time? *

YES

NO

9. Have you had surgery, or been diagnosed with a disease in the past 3 months? *

YES

NO

If you answered yes to question 9, please enter the date:

MM

DD

YYYY

10. In the past 12 months, have you been told by a healthcare professional that you have an elevated cholesterol level or abnormal lipid profile, or are you on any medications to control your blood lipids? *

YES

NO

11. Do you currently smoke cigarettes, or have you quit within the past six months? *

YES

NO

12. Have your father or brother(s) had heart disease prior to the age of 55 or mother or sister(s) had heart disease prior to age 65? *

YES

NO

13. Within the past 12 months, has a health care professional told you that you have high blood pressure? (systolic >140 mmHg, diastolic >90 mmHg) *

YES

NO

14. Do you currently have high blood pressure, or are you taking medications to manage high blood pressure? *

YES

NO

15. Within the past 12 months, have you been told by a healthcare professional that you have an elevated fasting blood glucose level? (>100 mg/dl) *

YES

NO

16. Are you currently under the care of a healthcare professional for blood clots or other circulatory problems? *

YES

NO

17. Do you currently experience problems or pain in your bones, joints, or muscles that may be aggravated by exercise? *

YES

NO

18. Do you currently experience any back and/or neck discomfort or problems? *

YES

NO

19. Are you currently under the care of a healthcare professional for any other health/medical problems? *

YES

NO

Name *

First Name

Last Name

29. Have you been told by a healthcare professional that you should not exercise? *

YES

NO

Name *

First Name

Last Name

37. Do you eat a variety of foods from each of the food groups? *

YES

NO

38. Do you try to limit the amount of fat you eat to <30% of your total daily caloric intake? *

YES

NO

39. Do you use sugar sparingly by adding little to none to the foods you eat and by limiting your intake of desserts, candy, and soft drinks? *

YES

NO

I AGREE TO THE TERMS ABOVE: *

First Name

Last Name

DATE: *

MM

DD

YYYY