General Health Prole
To help further assess the safety of exercise for you, complete as much of this health prole as possible.
General Informaon
Age:
Total cholesterol: Blood pressure: /
Height:
HDL: Triglycerides:
Weight:
LDL: Blood glucose level:
Are you currently trying to
gain or
lose weight? (check one if appropriate)
Medical Condions/Treatments
Check any of the following that apply to you an d add any other condions that might aect your ability to exercise
safely.
heart disease
lung disease
diabetes
allergies
asthma
depression, anxiety, or other
psychological disorder
eang disorder
back pain
arthris
other injury to joint problem:
substance abuse problem
other:
other:
other:
Do you have a family history of cardiovascular disease (CVD) (a parent, sibling, or child who had a heart aack or
stroke before age 55 for men or 65 for women)?
List any medicaons or supplements you are taking or any medical treatments yo u are undergoing. Include the name of
the substance or treatment and its purpose. Include both prescripon and over-the-counter drugs and supplements.
Lifestyle Informaon
Check any of the following that is true for you, and ll in the requested informaon.
I usually eat high-fat foods (fay meats, cheese, fried foods, buer, full-fat dairy products) every day.
I consume fewer than 5 servings of fruits and vegetables on most days.
I smoke cigarees or use other tobacco products. If true, describe your use of tobacco
(type and frequency):
I regularly drink alcohol. If true, describe your typical weekly consumpon paern:
I oen feel as if I need more sleep. (I need about hours per day; I get about hours per day)
I feel as though stress has adversely aected my level of wellness during the past year.
Describe your current acvity paern. What types of moderate physical acvity do you engage in on a daily basis? Are
you involved in a formal exercise program, or do you regularly parcipate in sports or recreaonal acvies?
PRS 618 8/19
