Signature Print Name Phone Number CrossFit New Haven 1175 State St., Unit 207, New Haven, CT 06511 HEALTH HISTORY INFORMATION: NAME: TODAY’S DATE: ADDRESS: DATE OF BIRTH: AGE: GENDER: MALE/FEMALE PHONE : (HOME) EMAIL: (CELL) POSITION: (WORK) COMPANY: Please answer the following questions: Diagnosed hypercholesterolemia (total cholesterol greater than 200mg/dl or HDL less than 35 mg/dl) YES OR NO TOTAL CHOLESTEROL Diagnosed hypertension (blood pressure greater than or equal to 140/90 mg/dl) YES OR NO Any smoking habits YES OR NO Any past history YES OR NO Diabetes (adult or juvenile) YES OR NO Any family history of heart disease prior to the age of 55 YES OR NO Any drinking habits (alcohol) YES OR NO How much WOMEN: Are you 55 years of age or older YES OR NO MEN: Are you 45 years of age or older YES OR NO List any medications or allergies: List any and all surgeries, illnesses or injuries (ortho) that you have had or have: When was your last physical check up Please answer the following questions (please specify) Any heart/vascular problems: Any metabolic disease: Heart disease, heart attack, angina kidney disease Coronary angioplasty/cardiac surgery thyroid disorders Rapid heartbeats/palpitations liver disorders Heart murmurs or unusual cardiac findings Peripheral vascular disease Any respiratory disease: Stroke Asthma Other Chroni
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