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Answer Each Question by Printing the Necessary Information. Your Answers are Confidential

MEDICAL INFORMATION _______________________________________________________________________

Are you under the care of a physician, chiropractor, or other health care professionals for any reason? if yes, list reasons:
Are you taking any medications? (if yes, complete the following- type, dosage/frequency, reason for taking):
Has your doctor said your blood pressure was too high?
Are you over the age of 65?
Is there any reason not mentioned why you should not follow a regular exercise program? If yes, please explain?
Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?
Are you unaccustomed to vigrous exercise?
Have you recently experienced any chest pain associated with either exercise or stress? If yes, please explain