Water Exercise Health Screening Form

NAME:_____________________________________ PHONE:________________

EMERGENCY CONTACT PERSON:____________________  PHONE:________________

PHYSICIAN:________________________________ PHONE:________________

HAVE YOU EVER HAD?

DO YOU PRESENTLY HAVE?

High Blood Pressure               

YES

NO

YES

NO

Heart Disease/Chest Pain    

YES

NO

YES

NO

Diabetes                              

YES

NO

YES

NO

Epilepsy                               

YES

NO

YES

NO

If you presently have any of the above conditions, are your symptoms controlled by medication?

Arthritis                                

YES

NO

YES

NO

High Cholesterol                       

YES

NO

YES

NO

Low Blood Pressure               

YES

NO

YES

NO

Asthma                                    

YES

NO

YES

NO

Lung Disease                       

YES

NO

YES

NO

Difficulty Breathing with Exercise

YES

NO

YES

NO

Pain or Cramps in the Legs   

YES

NO

YES

NO

Dizzy Spells with Exercise      

YES

NO

YES

NO

"Bad Back"                           

YES

NO

YES

NO

Ankle, Knee, Shoulder Problems

YES

NO

YES

NO

Have you had surgery during the past 3 months?      YES         NO

If yes, please explain:

Are there any other health conditions, that your exercise instructor should be aware of?

If so, please explain:

What are your goals for this class?