Health and Wellness Consent and Release Form
Please answer the following questions as accurately and completely as possible. Your answers will be used to
determine your physical readiness for exercise. All information will be kept strictly confidential
Circle the appropriate response.
1. Has your doctor ever told you that you have a heart condition?
YES NO
If yes, please explain__________________________________________________________________________________
2. Has your doctor ever told you that you have high blood pressure?
YES NO
If yes, please explain__________________________________________________________________________________
3. Has your doctor ever told you that you have elevated cholesterol?
YES NO
If yes, what is your cholesterol level __________________________________________________________________
4. Have you ever had any chest pains?
YES NO
If yes, please explain __________________________________________________________________________________
5. Do you have a family history of heart disease?
YES NO
If yes, please explain __________________________________________________________________________________
6. Have you ever experienced dizziness or fainting?
YES NO
If yes, please explain__________________________________________________________________________________
7. Has your doctor ever told you that you have diabetes mellitus?
YES NO
8. Are you presently taking any prescription medications?
YES NO
If yes, please indicate medication and the condition for which it has been prescribed.
______________________________________________________________________________________________________
9. Do you have any bone or joint problems?
YES NO
If yes, please explain __________________________________________________________________________________
10. Do you smoke?
YES NO
11. If female, are you over 50? If male, are you over 40?
YES NO
12. Is your current lifestyle sedentary?
YES NO
13. Has your doctor ever told you that there is a physical reason for you NOT to exercise?
YES NO
If yes, please explain__________________________________________________________________________________
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