Common sense is your best guide in answering these few questions.  Please read carefully and check YES or NO opposite the question if it applies to you.  If yes, please explain.  

YES NO  

____ ____1. Has you doctor ever said you have heart trouble?

YES__________________________________________

____ ____2. Do you frequently have pains in your heart or chest?

YES__________________________________________

____ ____3. Do you often feel faint or have spells of severe dizziness?

YES__________________________________________

____ ____4. Do you have high blood pressure?

YES__________________________________________

____ ____5. Do you have bone/joint problems such as arthritis that

that might be aggravated by exercise?

YES__________________________________________

____ ____6. Is there another physical reason, not mentioned

here why you should not follow an activity program?

YES__________________________________________

____ ____7. Do you suffer from low back pain or numbness?

YES__________________________________________

____ ____8. Are you currently taking any medications?

If yes please specify?

YES__________________________________________

_______________________________ _______

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*Please print this page and return with your payment at the first class.