"A program for every Body"

BODY SYSTEMS FITNESS CONSULTANTS MEDICAL HISTORY QUESTIONNAIRE   Prior to participation in any Body Systems Fitness Consultants Fitness Programs or Personalized Prescriptions, it is required that you complete the following Medical Questionnaire and Liability Waiver. The medical, health and fitness data collected herein will help Body Systems Fitness Consultants develop programs and prescriptions that will meet your individual needs. We strongly suggest a physical examination before participating. We strongly encourage individuals 35 years or older to have a maximal stress test prior to participation in any fitness program.                                                                                                                                                              Date:              Name:      Address:  Home:      Business:  Email:        Personal Physician:       Physician Address:        Phone:                         Date of Last Physical:   Age:    Height:    Weight:    MEDICAL HISTORY Please check any boxes that apply if you ever have had or are presently suffering from any of the following health problems: Heart Disease Hernia Tuberculosis Varicose Veins Stroke Back/Neck Pain High Blood Pressure Gout Emphysema Poor Eyesight Arthritis Hard of Hearing Bone/Joint Problems Asthma Kidney Disease Epilepsy High Cholesterol Muscle/Tendon Problems Diabetes   Allergies Rheumatic Fever Peripheral Vascular Disease   If "YES" to any of these conditions, please describe   Have you ever been under a physicians care for any reason during the past year?  Yes  No If "YES", please describe:   Are you presently taking any medications?  Yes  No If "YES", please describe   Have you had any surgery?  Yes  No If "YES", please describe   When you exercise, do you experience any of the following: Shortness of Breath Dizziness Leg Cramps Headaches Coughing Swelling/Discomfort in Joints       Do you experience any pain in: Chest Shoulders Neck and Jaw Lower Back Do you ever feel as if you are under stress, anxious, nervous?  Yes  No How do you cope with it?