USAG Wiesbaden Sports & Fitness Branch

Program Medical History Form

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General Information:

Name:__________________________________________Date:___/___/_____

Address:__________________________________________________________

City:_______________________State:___________Zip:___________________

Telephone: (home)__________________________(work)___________________

Age:______Sex:________Height_______Weight:_______GoalWeight_________

Physician:_______________________Diagnosis___________________________

1. Has your doctor ever said you have any cardiovascular problems? Yes / No

2. Do you frequently suffer from chest pains? Yes / No

3. Have you ever had a heart attack? Yes / No

4. Do you ever experience an irregular or racing heart rate during exercise

or at rest? Yes / No

5. Do you often feel faint or have dizzy spells? Yes / No

6. Has a doctor ever said your blood pressure was too high? Yes / No

7. Do you often have trouble breathing? Yes / No

8. Has a doctor ever told you that you have a bone or joint problem such as

arthritis that has been aggravated by exercise, or might be aggravated with

exercise? Yes / No

9. Is there a good physical reason not mentioned here why you should not follow

an activity program even if you wanted to? Yes / No

10. Are you over age 55 and not accustomed to vigorous exercise? Yes / No

11. Are you diabetic? Yes / No

12. Are you pregnant? Yes / No

Signature: __________________________________________ Date: __________________