Heart Attack, Coronary Bypass, Cardiac Surgery or Stroke
Abnormal Resting or Stress ECG
Uneven, Irregular, or Skipped Heart Beats
(Including a Racing or Fluttering Heart)
Abnormal Blood Lipids (Total serum cholesterol >200 mg/dL;
HDL<35 mg/dL; LDL>130 mg/dL or total cholesterol to HDL ratio >5)
Diabetes
High Blood Pressure (> than 140 mmHg over 90 mmHg)
Phlebitis (Deep Vein Thrombophlebitis)
Pulmonary Disease (Asthma, Emphysema and Bronchitis)
Rheumatic Fever
Light Headedness, Fainting or Seizures
Chest Pain at Rest or Exertion
Unusual Shortness of Breath
Orthopedic Problems
(Arthritis or any other Bone, Joint or Muscle Problems)
70 Years of Age or Older
Obesity (BMI > than 30)
[Enter HEIGHT ______] [Enter WEIGHT ______] [Enter BMI ______]
Do you know of any other reason why you should not do
physical activity?
________________________________________________
[SECTION 2]
Family history of coronary or other atherosclerotic disease
prior to age 55 male, 65 female.
Emotional Disorders [Please List]
________________________________________________
Medications [Please List]
________________________________________________
Drug Allergies [Please List]
________________________________________________
Smoking
Physical Inactivity
Male over age of 44 or Female over age of 54
Recommendations / Health Status Classification
(This section is for Personal Trainers to fill out.)
If YES to (one) or more questions from SECTION 1 or (two) or more questions from SECTION 2 client must get a PHYSICIAN'S APPROVAL and sign a WAIVER before beginning personal training program. If NO to all questions in SECTION 1 and 2, client can begin an exercise program.
Client may begin a personal training program.
DELAY training program because of temporary illness such as cold or fever.
DELAY training because client either is or may be pregnant. Client must talk to their doctor before they start becoming more active.
Client must receive PHYSICIAN'S APPROVAL and sign a WAIVER before beginning personal training program.
Unable to train. Client should work with a doctor or physical
therapist on a medically supervised exercise program.
"I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction."
Client Name (Please Print)
Emergency Contact (Name)
Today's Date
Signature
Emergency Contact Phone #
Witness
NOTE: You may be able to do any activity you want - as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. This physical activity clearance shall become invalid if your condition changes so that you would need to check off (one) or more items not currently marked in SECTION 1. YOU MUST NOTIFY YOUR PERSONAL TRAINER OF ANY CHANGES IN YOUR HEALTH STATUS OR MEDICAL CONDITION.
PRIVACY: The information provided on this form will be used as an aid to provide proper personal training guidance while you are a client of a WeBeFit trainer. This information will not be released without your knowledge and consent.
PARENT or GUARDIAN name and signature are required beside the name and signature of any person not 18 years of age or older.
