Risk Factor Assessment
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If you mark two or more of the statements in this section YES you should consult your physician or other appropriate health care as part of good medical care and progress gradually with your exercise program. You might benefit from using a facility with a professionally qualified exercise staff to guide your exercise program.  

Professionally qualified exercise staff refers to appropriately trained individuals who possess academic training, practical and clinical knowledge, skills, and abilities commensurate with credentials.

 
Are you a man 45 years of age or higher? *

     
 
Are you a women 55 years of age or higher? *

     
 
Do you smoke or have you quit smoking within the previous 6 months? *

     
 
Is your blood pressure greater than or equal to 140/90 mm Hg? *

     
 
Do you take blood pressure medication? *

     
 
Is your blood cholesterol level greater than or equal to 200 mg/dL? *

     
 
Is your LDL level greater than or equal to 130 mg/dL? *

     
 
Do you have a close blood relative who had a heart attack or heart surgery before age 55(father or brother) age 65 (mother or sister)?

     
 
Have you been physically inactive (i.e., you get less than 30 minutes of physical activity on at least 3 days per week)? *

     
 
Your body mass index is greater than or equal to 30 kg/m? *

     
 
Are you pre diabetic? *

     
 
Please list if you do not know your blood pressure, cholesterol level, pre diabetic, or any other information we may need to know below.

 
First and Last Name: *

 
Date: *

 
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