Medical Condition Form
MEDICAL CONDITION FORM
This form is a collection of data to keep you safe while performing exercises and in case of emergency. All contents will be kept confidential between Diane Simmons, fitness instructors on a need to know basis, front desk staff and other medical professionals if a medical crisis arises.
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
YES NO
In the past month, have you had chest pain when you were not performing any physical activity?
YES NO
Do you lose your balance because of dizziness or do you ever lose consciousness?
YES NO
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
YES NO
Have you ever had any surgeries? (If yes, please explain and provide date of surgery.)
YES NO Explain:
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?
YES NO Explain:
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
YES NO Explain:
(Complete the back page)
Are you currently taking any medication? (If yes, please list.)
YES NO Explain:
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.)
YES NO Explain:
Do you have any other medical conditions or reasons that may affect your ability to perform exercises in this camp?
YES NO Explain:
If you answered yes to any question, has your doctor cleared you to exercise? Do you know of any other reason why you should not engage in physical activity?
YES NO Explain:
Printed Name ______________________________________________________________
Signature __________________________________________________________________
Date ______________________________________________________________________
