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Health History Questionnaire

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QUESTION
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* Are you taking any medications? If yes, please describe:


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* Do you have a history of heart problems? If yes, please describe:


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* Do you have a history of high blood pressure?
* Have you ever had a stroke?
*
Has anyone in your family under the age of 50 died from heart problems?
* Have you ever had chest pains?
* Do you frequently feel faint or dizzy?
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Do you ever have to stop exercising because of shortness of breath?
* Do you smoke?
* Do you have diabetes?
Women:  Are you currently pregnant?
* Have you had a pulmonary disease, asthma, emphysema?
* Do you have any drug allergies?
* Have you had a physical from your doctor?
* Have you had back problems?
* Have you gained or lost 10 pounds or more in the past year?
* Any other injuries, If yes, please explain:


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*
Any other significant physical condition or medical information not mentioned above that may be of importance?  If yes, please explain:


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