Health, Physical Education, and Recreation
Health Fitness Evaluation- Medical Information

 

Please complete the following questions accurately. The information provided to the Wellness Testing Center is confidential and will enable us to offer personalized attention to your individual goals and needs.

Please Mark All That Apply

Your History Rheumatic Fever Heart Murmur High Blood Pressure Any Heart Trouble Disease of Arteries Varicose Veins Lung Disease Injuries to the Back Epilepsy Diabetes Gout Operations Explain:

Family History High Blood Pressure High Cholesterol Heart Attack Stroke Diabetes Congenital Heart Disease Heart Operations Early Death Other Family Illnesses   Explain:

If anyone in your family has ever had a heart attack or stroke, please list their relation to you
and their age at the time of the heart attack or stroke.

Relation to you: Age:

Present/Recent Symptoms Review Chest Pain/Discomfort Shortness of Breath Heart Palpitations Cough on Exertion Coughing of Blood Back Pain Arthritis/Swollen, Stiff Joints Orthopedic Problems

Medications Taking Now None Anti-arrhythmias Dieretics & Electrolytes Tranquilizers or Sedatives Metabolics (Insulin, Thyroid) Other:

Do you know of any medical condition that might make it dangerous for you to participate in vigorous exercise?
Yes No

If yes, explain:

Please type your email address so that we can contact you:

First Name:  

Last Name:

     

If you have any questions, please call the Wellness Testing Center at 782-5114.

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