1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? *
Yes
No | If yes, list medications:
|
2. Do you take any prescribed medication on a permanent or semi-permanent basis? *
Yes
No
| If yes, list medications:
|
3. Do you have a seizure disorder (epilepsy)? *
Yes
No |
4. Do you have diabetes (adult or juvenile)? *
Yes
No | If yes, list type and medications:
|
5. Have you ever been found to be anemic (low blood count)? *
Yes
No |
6. Do you have High Blood Pressure (hypertension)? *
Yes
No | If yes, list medications you are taking:
|
7. Do you have or have you ever had the following diseases?
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8. Do you have asthma? *
Yes
No | If yes, list medications you are taking:
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9. Have you ever had a severe neck injury? *
Yes
No | If yes, describe:
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10. Have you ever been knocked unconscious? *
Yes
No | If yes, describe:
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11. Do you wear glasses or contact lenses? *
Yes
No |
12. Have you had a broken bone or fracture in the past 2 years? *
Yes
No | If yes, describe:
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13. Have you ever injured your back? *
Yes
No | If yes, describe:
|
| 14. How often do you have back pain?
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15. Have you had knee pain in the past 2 years that has disabled you for longer than a week?*
Yes
No | If yes, describe:
|
16. Do you have other physical conditions/limitations that cause pain? *
Yes
No | If yes, describe:
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17. Have you had any surgical procedures?*
Yes
No | If yes, describe:
|
18. Are you pregnant? (Women ONLY)
Yes
No |
19. Have you participated in a regular exercise or counseling program in the past? *
Yes
No | If yes, describe type and how often:
|
20. Are you training for a specific event? *
Yes
No | If yes, explain:
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21. What are your lifestyle and/or fitness goals for the next three months?*
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