Internstional Sports Sciences Associstian s"w.$, Fast Lane Fitness ...J.. .. ' . "ri. ,: :r: '..., ....:.. :r ..,..-i::.:.:-.-. 'ri ..lll. :.,., - i'] .. r.,. .. I , . jii liilllijitil.l,itil Screening Question naire ,iii.i.i,l,:.1i.,.,i Date of Birth: Name: Age: Address: City, State, Zip: Home Phone: Work Phone: Employer: Occupation: D Yes DNo il Yes t-l No 3 Yes O t'lo tl Yes t-] No Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction, coronary insufficiency, or thrombosis? O Yes flNo Have you ever had rheumatic fever? il Yes ll Do you have diabetes, hypertension, or high blood pressure? ft Yes trNo tll Yes DNo D Yes DNo tr Yes DNo fl Yes flNo Have you ever taken nitroglycerine or any other tablets for chest pain-tableS you take by placing under the tongue? ll Yes f,No Are you overweight? D Yes trNo Are you under a lot of stress? tll Yes DNo Do you drink excessively? tl Yes DNo Do you smoke cigarettes? fl Yes ONo Do you have a physical condition, impairment or disability, including a joint or muscle problem, that should be considered before you undertake an exercise program? fl Yes ll Are you more than 65 years old? D Yes n ffo i Yes nUo t-l Yes ilNo Has your doctor ever said you have heart trouble? Have you ever had angina pectoris, sharp pain, or heavy pressure in your chest as a result of exercise, walking, or other physical activity such as climbing stairs? (Note: This does nat include the normal out af breoth feeling that results from normal acti\tity) Do you experience any sharp pain or extreme tightness in your chest when you are hit with cold blast of air? Have you ever experienced rapid heart action Does anyone in or palpitations? yourfamily have diabetes, hypertension, or high blood pressure? Has more than one blood relative (parent, sibling, first cousin) had a heart at[ack or coronary artery disease before the age of 60? Have you ever taken medications Have you ever taken dlgitalis, Are or been on a special diet to lower your cholesterol? quinine, or any other drug for your heart? you more than 35 years old? Do you exercise fewer than three times per week? diet,mdphysiaia.tirdly- a No No s'reen 0805