Health History Form

Health History Form

Name
Name
First
Last
Are you pregnant?
Do you consider yourself:
Mark the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest):
Please indicate if you have or have had any of the following:
Alcoholism
Back Condition
Drug Addiction
Fatigue
Hernia
Migraine
Shortness of Breath
Varicose Veins
Allergies
Bursitis
Eating Disorder
Fibromyalgia
High Blood Pressure
Nervous Tension
Sinus
Arthritis
Carpal Tunnel
Environmental Sensitivities
Heart Trouble (any)
Low Blood Pressure
Osteoporosis
Tight Shoulders
Asthma
Diabetes
Epilepsy
Heart Condition
Joint Pain
Sciatica
Ulcers
Fibromyalgia
I certify to the best of my knowledge the above information is correct and complete. I also understand that Dot Spaet assumes no responsibility for any illness, accident or injury I may incur from the use of the programs, services or facilities. All individuals are strongly encouraged to consult with a physician before entering a non-medically supervised exercise program.