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Are you currently taking any medications or drugs?
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If Yes, please give details
Medical Information
History of heart problems, chest pain, or stroke
Yes
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Increased Blood pressure
Yes
No
Any chronic illness or condition
Yes
No
Difficulty with physical exercise
Yes
No
Advice from physician not to exercise
Yes
No
Pregnancy(now or within the last 3 months)
Yes
No
History of breathing or lung problems
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Muscle, joint, or back disorder
Yes
No
Diabetes or thyroid condition
Yes
No
Use tobacco products
Yes
No
Increased Cholesterol
Yes
No
History of heart problems in immediate family
Yes
No
Hernia or other condition which lifting weights could aggravate
Yes
No
If you answered Yes to any of these, please give details
Please consult with a doctor before starting any exercise program.
524 Wards Corner Road ~ Loveland, OH 45140 ~ Phone: 513.677.2900 ~ Fax: 513.677.6182
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