YMCA AOA HEALTH SCREEN FORM
Address________________________________________
Date of Birth________________Phone_______________
Male___Female___Age____Height_____weight______
Class Time: 7am_____9am_____9am(t/th/f)_________
This form is intended to obtain revelent information about your health that will assist the staff in helping you with this program.
Please answer all questions to the best of your
knowledge.
1.
BLOOD PREASURE
Do you have high blood preasure? Yes_____ No_____
Have you had high blood preasure in the past?
Yes_____ No_____
Are You on medication for high blood preasure?
Yes_____ No_____
2.
SMOKING
Do you smoke? Yes_____ No_____If yes,how many per
day?________
Are you a former smoker? Yes_____ No_____ Date you quit________
3.
DIABETES
Do you have diabetes? Yes_____ No_____
4.
HEART PROBLEMS
Have you ever had a heart attack? Yes_____ No_____
Heart surgery? Yes_____ No_____
5.
FAMILY HISTORY
Have any of your blood relatives had heart disease
or heart surgery?
Yes_____ No_____
6.
ORTHOPEDIC PROBLEMS
Do you have any orthopedic problems that may
prevent you from exercising? Yes_____ No_____
7.
OTHER PROBLEMS
do you have any other problems that may prevent you
from participating? Yes_____ No_____
8.
MEDICATIONS
_____________________________________________________________
_____________________________________________________________
9. EMERGENCY
Please list a relative whom we may contact in case
of an emergency.
Name________________________________Phone_________________
Relation_____________________________________________________