Medical Questionnaire

: __________________ Address: _______________________________________________________________________________________ Street City State Zip Phone (H): ____________________ (W): ____________________ E-mail address: __________________________ In case of emergency, whom may we contact Name: ______________________________________ Relationship: _____________________________________ Phone (H): ________________________________________ (W): _______________________________________ Personal physician Name: __________________________________ Phone: ____________________ Fax: ____________________ Present/Past History Have you had OR do you presently have any of the following conditions (Check if yes.) ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Rheumatic fever Recent operation Edema (swelling of ankles) High blood pressure Injury to back or knees Low blood pressure Seizures Lung disease Heart attack Fainting or dizziness with or without physical exertion Diabetes High cholesterol Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack) nocturnal dyspnea (shortness of breath at night) Shortness of breath at rest or with mild exertion Chest pains Palpitations or tachycardia (unusually strong or rapid heartbeat) Intermittent claudication (calf cramping) Pain, discomfort in the chest, neck, jaw, arms, or other areas with or without physical exertion Known heart murmur Unusual fatigue or shortness of breath with usual activities Temporary loss of visual acuity or speech, or short-term numbness or weakness in one side, arm, or leg of your body Other Family History Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions (Check if yes.) In addition, please identify at what age the condition occurred..