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BUCKS COUNTY COMMUNITY COLLEGE FITNESS CENTER (Bucks County Community College)

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BUCKS COUNTY COMMUNITY COLLEGE
FITNESS CENTER
Please check one:
□ Student
□ Faculty/Staff
□ Alumni
□ VIP/Retiree
Health History Form
Please write neatly.
Last: _________________________ First: _____________________ DOB: _____________ Sex: ________
Street: _________________________________________________________________________________
City/ST/Zip: ___________________________________ Phone: _____________________ BCCC ext. ______
Emergency Contact: ________________________________ Phone: _____________________
ALL INFORMATION ON THIS FORM WILL BE KEPT CONFIDENTIAL
Are you taking any medications or drugs? Y N If so, please list the medication, dose, and reason:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Do you have now, or have had in the past: (If yes, please explain on line below) Yes No
1. History of chest pain, breathing or lung conditions? 
2. History of stroke or aneurisms? 
3. Family history of heart conditions?
4. High blood pressure (>140/90)? 
5. High cholesterol (>200 mg/dL)? 
6. Any chronic illness or condition? 
7. Any recent surgery (within the past 12 months)? 
8. Any muscle, joint, spine, or previous injury still affecting you? 
9. Diabetes or thyroid condition? 
10. Cigarette smoking habit? 
11. Any condition that may be aggravated by lifting weights (i.e. hernia)? 
12. Difficulty with physical activity? 
13. Recent or currently pregnant? 
14. Any limitations given to you by your physician? 
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Any other reason(s) that may restrict your physical activity not mentioned above? Y N
If yes, please explain: ____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I understand the nature and purpose of this health history form. I declare that, to the best of my
knowledge, that my answers are true, correct, and complete.
Signature: ______________________________________ Date: ___________________
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BUCKS COUNTY COMMUNITY COLLEGE
FITNESS CENTER
Agreement and Release of Liability
In consideration of being allowed to participate in the activities and programs of the Bucks County
Community College Fitness Center, and use of the facilities, equipment, and other resources, I do hereby
waive, release, and forever discharge the Bucks County Community College Fitness Center staff from any
and all responsibilities or liability from injuries or damages resulting from my participation in any activities
or use of equipment within the Fitness Center.
If you agree, please initial ___________
I understand and am aware that strength, flexibility, and aerobic exercise, including the use of equipment,
is a potentially hazardous activity. I also understand that fitness activities involve the risk of injury or death,
and that I am voluntarily participating in these activities and using equipment and machinery with the
knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of
injury or death.
If you agree, please initial ___________
I do hereby further declare myself to be physically sound and suffering from no condition, impairment,
disease, infirmity, or other illness that would prevent my participation in a physical fitness program. I do
hereby acknowledge that I have had a physical examination and have been given my physician’s permission
to participate, or that I have decided to participate in a physical exercise program without the approval of
my physician and do hereby assume all responsibility for my participation and activities.
If you agree, please initial ___________
_____________________________________________________ __________________________
Print Name Student ID # / Employee Dept.
_____________________________________________________ __________________________
Signature Date
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BUCKS COUNTY COMMUNITY COLLEGE FITNESS CENTER (Bucks County Community College)

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Completed 4 February 2021

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