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Health History Form
Home
About
Services
SallysBio
Transformations
Contact Us
Gallery
Health History Form
Sally's Fitness Fortess
Success is following the script
Please complete the health history form below.
Name
Email
Date
Age
Gender
Male
Female
Other
Physician's Name
Physician's Phone
Are you taking any medications?
Does your physician ask you to inform them before entering an exercise program?
Yes
No
Describe any physical activity you do regularly.
Do you have a history of heart problems, chest pains or stroke?
Yes
No
High Blood Pressure?
Yes
No
Any chronic illness or condition?
Yes
No
History of heart problems in immediate family?
Yes
No
Hernia or any condition aggrevated by lifting wieghts?
Yes
No
Surgery in last 12 months?
Yes
No
Pregnancy now, or in last 3 months?
Yes
No
History of breathing or lung problems?
Yes
No
Muscle, joint, back disorder or previous injuries?
Yes
No
Diabetes or thyroid condition?
Yes
No
Do you smoke?
Yes
No
Obesity, over 20% of normal body weight?
Yes
No
Increased blood cholesterol?
Yes
No
Explain any Yes answers below.
Submit
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