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1.
Do you participate in regular physical activity?
(i.e. moderate exercise, three times a week)
List activities:
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Yes
No
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2.
Have you ever had a heart attack?
When?
Did you attend cardiac rehabilitation?
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Yes
No
Yes
No
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3.
Do you have high blood pressure, heart murmur, or heart disease?
Circle which one and explain:
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Yes
No
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4.
Are you taking any medication (i.e. digitalis, quinidine,
nitroglycerine) or any other drug for a medical condition?
What is your condition?
Name of drug (s):
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Yes
No
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5.
Do you ever have chest, neck, shoulder or arm pains or pressure
during or after exercise? Please explain:
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Yes
No
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6.
Is your heartbeat irregular, or do you have spells where it is
suddenly fast? Please explain:
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Yes
No
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7.
If you walked on a level mile at an average pace, would you get out
of breath, have pain in your chest or legs, or develop extreme tiredness?
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Yes
No
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8.
Do you have bone or joint problems such as arthritis or
osteoporosis?
Please explain:
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Yes
No
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9.
Do you have Diabetes? Type 1 or 2?
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Yes
No
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10.
Do you have Asthma? Is it exercise induced?
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Yes
No
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11.
Do you have any allergies? Please list:
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Yes
No
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12.
Do you smoke? How many a day?
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Yes
No
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13.
Have you ever hiked
before? (snowshoe or ski for winter session)
Which one?
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Yes
No
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