| Basic Information: |
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| First Name:
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| Last Name:
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| Full Address:
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| How can I contact you:
Phone numbers:
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| Best time to reach you:
E-mail address:
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| How did you find out about Healthy Results :
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What Training Camp are you interested in?:
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| Choose an event below :
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Please make all cheques payable to:
Healthy Results
19 Second Ave
Orangeville, ON
L9W 1H5 |
Your Health History: |
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| 1. Do you have, or has anyone in your family ever had coronary
artery disease?: |
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If yes please explain:
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| 2. Do you ever experience chest, shoulder, neck, or arm
pains after exercise?: |
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If yes please explain:
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| 3. Have you ever fainted, felt dizzy, or unusually winded
after exercise? |
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If yes please explain:
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| 4. Has a doctor said that your blood pressure is too high
or uncontrolled? |
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If yes please explain:
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5. Has a doctor ever said you have heart trouble, a heart
murmur,
or that you have had a heart attack? |
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If yes please explain:
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| 6. Are you diabetic, have a thyroid condition, or any chronic
condition? |
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If yes please explain:
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| 7. Are you using any medications? List Them |
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If yes, please list medications you are taking:
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| 8. Is your cholesterol level high? |
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If yes, what's your cholesterol count?
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9. Have you ever had a complete physical exam including
stress test
on a treadmill or ergometer? |
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When did you take the test (please include
copy of results):
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| 10. Do you have any condition that a doctor says may limit
your exercise? |
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If yes please explain:
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| 11. Have you ever smoked?: |
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When did you quit?:
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| 12. Have you ever had a joint or back disorder or any current
injury? |
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If yes please explain:
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| 13. Have you had surgery in last 12 months? |
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If yes please explain:
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| 14. Are you now, or have you been pregnant in last three
months? |
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If yes please explain:
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