MEDICAL HISTORY QUESTIONNAIRE

The purpose of this form is to have more specific medical information and family history. Please complete this form to the best of your abilities.

MEDICATION

1. Are you currently taking medication (prescribed or over the counter)? If yes, please provide medication name, dose and frequency.

SIGNS AND SYMPTOMS

2. Have you ever had the feeling that your heart is suddenly beating faster, racing or skipping beats, either at rest or during exercise?

3. Have you ever had pain or cramping in the leg/calf with physical activity that goes away when you slow down or stop? If yes, please describe when this occurs.

4. Is there a history of heart problems or sudden death before 55 years of age and father or other male first-degree relative or before 65 years of age and Mother or other first grade relative? If yes, please specify the condition and relationship to you (e.g. heart attack, mother).

SURGICAL HISTORY & PHYSICAL CONDITIONS

5. Have you had any past surgeries? If yes, please provide a list (e.g. knee surgery, 2015).

6. Please list all physical conditions, both past and present (e.g. shoulder strains, lower back problems, etc.).

7. If you selected any physical conditions in Question 6, is this a current issue?

8. Do you have difficulty or pain getting up from the floor?

9. Do you have difficulty or pain going up or down the stairs?

10. Do you have any of the following medical conditions?

OCCUPATION AND LIFESTYLE

11. What is your current occupation?

12. What is your current stress level (1 = minimal stress, 10 = extremely stressed)?

13. If you are currently physically INACTIVE what is the main reason for your inactivity?

14. If you are currently physically ACTIVE, what is/are your main physical activity(ies)?

15. Do you currently engage in the following lifestyle habits:

Your electronic signature confirms that you have answered the above questions truthfully. Please note, this information is strictly confidential.