Pre-Exercise Screening Want create site? Find Free WordPress Themes and plugins. Step 1 of 19 5% Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email Please list ALL of your physician’s full names, phone number and mailing address: Age0-2930-3940-4950-5960+ GenderMaleFemale An immediate family member has heart disease, high blood pressure, high cholesterol, or has had a heart attack or strokeat or before the age of 55between the ages of 56 to 65after the age of 65No member of your immediate family (parents, brothers or sisters) has had a heart attack or stroke, or had heart disease, high blood pressure, high cholesterol. Personal HistoryYou have had a prior heart attack, angina, or strokeYou have high blood pressure (140/90) or higherYou have high cholesterol (higher than 240 ml)You have no history of heart disease, high blood pressure or high cholesterol and have never suffered from a heart attack or stroke SmokingYou currently smoke 20 or more cigarettes per dayYou currently smoke up to 19 cigarettes per dayYou are a non-smoker but smoked previouslyYou have never smoked AlcoholYou drink more than 4 alcoholic drinks per dayYou drink more than 2 alcoholic drinks per dayYou drink less than 1 alcoholic drink per dayYou do not drink at all Medical History: Do you suffer from the following?DiabetesArthritisPsychological DisordersAsthmaEpilepsyBack or Neck ProblemsDetails: Weight: Would you assess yourself as beingVery OverweightOverweightIn a healthy weight range EXERCISE:No activity at all in a typical weekNon-aerobic exercise (slow walking, gardening, doubles tennis, manual work, etc.) for at least 2 hours per weekAerobic exercise for 20 minutes 1 or 2 times per weekSome form of aerobic exercise (jogging, brisk walking, swimming, cycling, aerobics, etc.) for at least 20 minutes at least 3 x per week STRESS:HighModerateLowVery LowSome of the more common characteristics of high stress levels are: Headaches, tension, pressed for time, easily angered, poor sleeping and lack of concentration. Please rate your level of stress. Have you ever had any bone, muscle or joint condition, which might be aggravated by exercise? Yes No What type of injury/condition occurred and when:Describe any medical treatment you receive i.e., surgery , physical therapy, and medications.Do you have any restrictions due to this injury? Are you currently pregnant? Yes No I certainly hope not If yes, how far along are you? PLEASE CHECK THE APPROPRIATE BOXES BELOW FOR THOSE WHICH APPLY TO YOU: (PAST OR PRESENT) Aortic Aneurysm Bladder Problems or Incontinence Excessive Fatigue Musculoskeletal Disorder Valvular Heart Disease Thyroid Problems Poor Tolerance for Exercise Nervous or Emotional Problems History of Surgery Gastro/Intestinal Problems Arrhythmia’s Coronary Heart Disease Orthopedic Disorder Irregular Heartbeats Anemia Broken Bones COPD Skin Conditions Arthritis Phlebitis Cancer Epilepsy Seizures Heart Murmur Overweight Stroke Gout Kidney Disease Ulcers Low Back Pain Do you have other chronic illnesses, injuries or disabilities? Please explain: Are you on any medications, including aspirin, cold medicines, and herbal diet supplements? If YES, please list: When was your last thorough physical examination? Results:Have you ever had a treadmill stress test or some other type of exercise test? Yes No AQUATIC INFORMATION:Do you have allergies to chlorine or other pool chemicals? Yes No Do you have a condition, which may restrict you from using the Steam Room or Whirlpool? (i.e. coronary disease, high blood pressure, pregnancy) Yes No Please Explain:What depth of water are you comfortable in? (Please check the depth level) Waist Chest Shoulder Deep I declare that the information I have given above is true and correct. I understand that there are risks inherent to any exercise program. Such risks include, but are not limited to, risk of slip, trip, fall, personal injury, and health problems, such as cardiac arrest or stroke, any of which could result in serious bodily injury or death, and I willingly and knowingly assume those risks. I knowingly and voluntarily release and hold harmless, for myself, my heirs, and personal representatives, the Silverlake Recreation Center, its owners, officers, members, agents, employees, and insurers, from any claim, liability, demand, action, and cause of action whatsoever, arising out of or related to any loss, damage or injury, I may sustain to myself or my property, however caused. This includes group exercise classes, personal exercise programs, health appraisals, advice and recommendations pertaining to nutrition, vitamins, and dietary supplements, and any other form of exercise, given or coordinated by the Silverlake Recreation Center, its agents or employees. I further agree to indemnify the Silverlake Recreation Center, its owners, officers, members, agents, employees, and insurers against any claim, liability, demand, action, costs, damages and expenses to which they may be liable.Signature Did you find apk for android? You can find new Free Android Games and apps.