DATE AND DESCRIPTION Sample Clauses

DATE AND DESCRIPTION. □ Heart Attack □ High Blood Pressure □ High Cholesterol □ Rheumatic Fever □ Heart Murmur □ Seizure/epilepsy □ Stroke □ High Blood Triglycerides □ Blood Clots □ Cancer □ Diabetes □ Asthma □ Gout □ Arthritis □ Osteoporosis □ Exercise-induced Asthma □ Thyroid Disorders □ Allergies □ Varicose Veins □ Hernia □ Obesity □ Anorexia □ Bulimia □ Severe Headaches □ Kidney Failure □ Kidney Removal □ Kidney Stones □ Kidney Dialysis □ Colitis □ Gall Bladder Removal □ Fibromyalgia □ Anemia □ Pregnancy □ Gall Bladder Disease/stones Have you ever experienced the following during exercise, after exercise or during a resting state? Please check all that apply. □ Shortness of breath or wheezing □ Side aches or side stitches □ Middle back pain □ Extremely high heart rate □ Irregular heart rate □ Shoulder pain □ Sharp Chest Pain □ Dull aching chest pain □ Foot or ankle pain □ Overall or one-sided weakness □ Loss of coordination □ Knee pain □ Heat intolerance □ Dizziness □ Low Back pain □ Mental Confusion □ Fainting □ Calf pain □ Vomiting □ Swelling of ankles or hands □ Hip pain/sciatica □ Cramping □ Shin Splints □ Arm or neck pain Please check all that apply and describe side effects □ Digitalis □ Anti-arrhythmias □ Diuretics and Electrolytes □ Metabolics □ Beta Blockers □ Tranquilizers or sedatives □ Vasodilators □ Alpha Blockers □ Calcium Channel Blockers □ Other □ Anti-inflammatory (Motrin, Advil) Have you ever suffered an injury at any of the following joints? If yes, please describe severity and frequency. Ankle (R or L) Knee (R or L) Hips Low Back Shoulder (R or L) Neck Other Do any of the joints above bother you during exercise? □ Yes, please explain below □ No Please check if anyone in your immediate family (grandparents, parent, and siblings) experienced any of the following. □ Heart Surgery □ High Cholesterol □ High Blood Pressure □ High Blood Triglycerides □ Diabetes □ Cancer □ Alzheimer’s □ Heart Operations □ Congenital Heart Disease _ □ Early death □ Other family illness Please check all that apply. Do you smoke? □ No □ Yes If you checked yes please select from the following □ Cigarettes □ Cigar □ Pipe If you checked any of the following, how many years have you smoked? □ Former Smoker If you checked the following, how long ago did you stop smoking? Do you drink alcoholic beverages? □ Yes □ No If you checked yes to the above question, how much do you drink (in ounces)in an average week? Do you drink caffeinated beverages? □ Yes □ No If you checked yes to the above ...