ASJJA Martial Arts Participation Health History Questionaire

Name:____________________________________________________________________

 

Age: _____ Birth Date: ________________

 

Past and Present Health History (check all that apply)

____ Diseases of the heart and arteries               ____ Abnormal electrocardiogram ECG

____ High Blood pressure                                   ____ Angina pectoris (chest pain)

____ Epilepsy Stroke                                         ____ Anemia

____ Abnormal Chest X-ray Cancer                     ____ Asthma or other lung disease

____ Orthopedic or muscular-skeletal problems    ____ Diabetes

 

If any other prior or pre-existing health conditions please list and explain: _______________________

_________________________________________________________________

_________________________________________________________________

 

If any of the above are checked or listed, please explain and indicate any recommendations your doctor has made regarding exercise: ______________________________________________________________

 

Is there a family history of heart disease, hypertension, stroke, diabetes, lung disease or epilepsy? (Circle one)    Yes     No

 

Any current prescription medications:_____________________________________________________

 

Level of Physical Activity:

 

___ Yes ___ No Are you currently involved in a REGULAR aerobic exercise program?

 

___ Yes ___ No Are you currently involved in a weight training program?

 

___ Yes ___ No Do you regularly perform stretching exercises?

 

What best describes your level of physical activity during the last 4-6 weeks: (Circle one)

 

Very Active        Moderately Active          Occasionally Active        Inactive

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