Health History Form Answer the following health questionaire in Yes or No Name* Sex* Male Female History of heart problem, chest pain or stroke?* Yes No High Blood Pressure* Yes No Any Chronic illness or conditions* Yes No History of heart problems in immediate family Yes No Hernia or any conditions that may be aggravated by lifting weights* Yes No Recent surgery( Last 12 months)* Yes No Pregnancy (Now or within the last 3 months) Yes No History of breathing or lung problems* Yes No Muscle, joint, back disorder, or any previous injury still affecting you* Yes No Cigarette smoking habits* Yes No Obesity ( more than 20% over ideal body weight)* Yes No Increased blood cholesterol* Yes No Please explain any " Yes" answers on the blank space below:Consent* I agree to the Terms and Conditions All the above information is true to any knowledge and I bond to inform the fitness center/ instructor whenever there is a change in my health status