Health History Form

The information obtained from this form will be treated as privileged and confidential and will not be released to any person or entity not associated with Haysboro Fit. The information you share will be utilized only to help make your experience as safe and enjoyable as possible. 

Has your doctor ever said that you have a heart condition?
Has your doctor ever said that you have high blood pressure?
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
Are you currently taking prescribed medications for a chronic medical condition?
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?

Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. 

Has your doctor ever said that you should only do medically supervised physical activity?
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?

Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).