Sonki Fitness
"Stronger, faster, leaner...for life!"

Participant Health History Form

Participant Name:                                                                                                         Age/Date of Birth:

Physician’s Name                                                                                                         Physician’s Phone #

Name and phone number of person to contact in case of an emergency:

Are you taking any medications including but not limited to beta blockers, diet pills or herbal supplements that may affect your heart rate or any other aspect of your performance and/or health in this class?

Does your physician know you are participating in this exercise program?

Do you have a physician’s release to engage in physical activity?

Do you now, or have you had in the past: (Explain on the back of this sheet)

1. History of heart problems   yes no

2. Increased blood pressure   yes no

3. Any chronic illness or condition   yes no

4. Difficulty with physical exercise   yes no

5. Advice from a physician NOT to exercise   yes no

6. Surgery within the last year   yes no

7. Pregnancy (now or within last three months)   yes no

8. History of breathing or lung problems   yes no

9. Muscle, joint, or back disorder   yes no

10. Diabetes or thyroid condition   yes no

11. Obesity (more than 20 percent over ideal body weight)   yes no

12. Increased blood cholesterol   yes no

13. History of heart problems in immediate family   yes no

14. Hernia, or any condition that might be aggravated by lifting weights   yes no

If you answered, "yes" to one or more of these listed conditions, you may be at increased risk of potential complications during a rigorous exercise program and need to get a signed release from your physician to participate in rigorous activity.

Remember, some form of exercise is almost always recommended, even in cases of increased risk. Exercise is known to help manage and ease conditions such as hypertension and diabetes. But in order to improve your quality of life, you need to make sure you’re not aggravating an existing medical condition or performing exercises that for you, may be contraindicated.

I have answered this health history form truthfully and understand it is in my best interest to obtain a physician’s release if I am at increased risk. I agree that Sonki Fitness reserves the right to demand a physician’s release:

SIGNATURE:                                                                 DATE: