Web Site Medical History Questionnaire To Be Completed Before Training First Name * Last Name * Phone # Emergency Phone# Emergency Contact Email Address * General Are You Under A Doctor's Care? * Yes No If yes, please explain briefly. Name of Doctor (Optional) Have You Ever Had A Stress Test? * Yes No Don't Know Results of Stress Test if Yes: Normal Abnormal Any Previous Operations * Yes No If yes, please list. Any Injuries? * Yes No If yes, please list. Have You Suffered Any of The Following? Heart Attack Stroke Cancer Select any that apply. Do You Smoke? * Never I used to but not anymore. Yes, I do currently. Do You Drink? * Not at all. Less than 3 drinks per week. More than 3 drinks per week. Date of Last Physical Are You Currently Taking Any Medications? * Yes No If yes, please list: Are Your Currently Taking Any Vitamins or Supplements? * Yes No If yes, please list: Do You Suffer From Any of The Following? High Blood Pressure High Cholestrol? Diabetes Heart Disease Chest Pain with Exertion Irregular Heartbeat or Palpitations Lightheadedness Shortness of Breath Leg or Feet Cramps Emphysema Metabolic Disorders (Thyroid etc) Epilepsy Asthma Back Pain Joint or Muscle Pain Mark All That Apply Do You Have Any Food Allergies? * Yes No If yes, please list all. Any Other Health Related Issues I Need To Know? (ie pregnancy, rehabilitation etc.) All information provided is held in strict confidence and is used only for the purposes of safe training & nutrition planning.