WORKSHEET 1: HEALTH AND FITNESS HISTORY

Personal Information

Name:

Phone: Address:

Age: Height: Weight: %body fat:

Class Time: Days of the Week:

Health History

Check the appropriate answer: Never Had Have Had Presently Have

Family History

Heart Disease

Chest Pain w/Exertion

Difficulty Breathing

High Blood Pressure

Low Blood Pressure

Pulmonary lung Disease

Diabetes

Epilepsy

Thyroid Disease

Hypoglycemia

Asthma

Arthritis

Persistent Headaches ,

Dizzy Spells

Bursitis

Varicose Veins

Obesity

Allergies

Bulimia

Anorexia Nervosa

Other

List any muscle injuries you have had (include dates):

List any bone or joint injuries you have had (include dates):

List any muscle, bone, or joint pain you are presently experiencing

Specify any medications you are presently taking:

Specify any activities you have been advised by a physician to avoid:

Specify any activities about which you must be cautious:

Do you smoke? Yes No If yes, how much?

Are you pregnant or have you had a baby within the last six months? Yes No

Do you have any other health condition that might limit your participation in this aerobics class?

Physical Fitness History

In your estimation, how physically fit are you right now?

Unfit Below Average Average Above Average Very Fit

Have you been exercising regularly? Yes No If no, how long has it been since you did?

If yes, describe your exercise program below.

Activity Frequency (times/week) Duration (time/session) Intensity (difficulty)

Briefly describe why you signed up for this course: