Name

Age

Address

Phone

Email

Athletes Info: Sport/ Position

Health History (Check all that apply)

History of heart problems
Increased blood pressure
Any chronic illness/disease
Difficulty with exercise
Physician restrictions
Recent surgery
Pregnancy
Breathing/lung problems
Diabetes/thyroid condition
Muscle/joint injury
Cigarette smoking habit
Obesity (>20%)
Increased cholesterol
Hernia

Please explain any "yes" responses