Vitality Details Your relation to main member? Principal Spouse Adult dependant Child

Medical History

Have you suffered from any of the following:	Yes/No
Heart trouble, angina, a heart attack, heart murmur, or stroke?
Pain or pressure in the left or mid-chest area, left neck, shoulder or arm, particularly during or shortly after exercise?
Feeling of faintness, severe dizziness or excessive breathlessness after mild exertion?
Advice from your doctor that your blood cholesterol level is/was elevated?
Diabetes?
Raised blood sugar?
A family history of coronary heart disease under age 55?
An abnormal resting electrocardiogram (ECG)?
Inactive lifestyle for 5 or more years AND aged 50 and over?
A medical condition not mentioned here which might need special attention in an exercise program, e.g. Arthritis, Recurrent Backache, Asthma?
Do you presently take beta-blocker medication, e.g. one or more of the following: Betapressin, Blocadren, Cardispare, Congard, Inderal, Inderetic, Lopsor, Pur-Bloka, Rexigen, Sectral, Sotacor, Sotazide, Tenoretic, Tenormin, Trasicor, Trasidrex,Visken.
If you are a smoker, how many cigarettes do you smoke per day?

If you said yes to any of the above, please elaborate. (Specify onset year and recovery year.)
If you have any alergies, please specify.