Medical
Date/Month/Year
Name of Contact
Are you currently under a doctor's care? *
Have you ever had an exercise stress test:
If yes, were the results:
Do you take any medications on a regular basis?
Have you been recently hospitalized?
Do you smoke?
Are you pregnant?
Do you drink alcohol more than three times/week?
Is your stress level high?
Are you moderately active on most days of the week?
Do you have
Do you have parents or siblings who, prior to age 55 had:
To the best of my knowledge, the above information is true. *
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