Name (First and Last):
* must provide value
Date of Birth (MM/DD/YYYY):
* must provide value
Street Address:
* must provide value
City:
* must provide value
State:
* must provide value
Zip Code:
* must provide value
Mobile Phone Number:
* must provide value
E-mail:
* must provide value
Are you currently a member of the MUSC Wellness Center?
* must provide value
Yes
No
Has your doctor ever said that you have a heart condition?
* must provide value
Yes
No
Has your doctor ever said that you have high blood pressure?
* must provide value
Yes
No
Do you feel pain in your chest at rest, during daily activities of living, or during physical activity?
* must provide value
Yes
No
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
* must provide value
Yes
No
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
* must provide value
Yes
No
If yes, please provide details here:
Are you currently taking prescribed medications for a chronic medical condition?
* must provide value
Yes
No
Please list all medications and conditions here:
* must provide value
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, tendon) problem that could be made worse by becoming more physically active?
* must provide value
Yes
No
If yes, please list all conditions here:
Has your doctor ever said that you should only do medically supervised physical activity?
* must provide value
Yes
No
Do you have Arthritis, Osteoporosis, of Back Problems?
* must provide value
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
Yes
No
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebrae (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?
Yes
No
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?
Yes
No
Do you have Cancer of any kind?
* must provide value
Yes
No
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head and/or neck?
Yes
No
Are you currently receiving cancer therapy (chemotherapy or radiation)
Yes
No
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm:
* must provide value
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer No if you are not taking medications for your condition)
Yes
No
Do you have an irregular heartbeat that requires medical management? (e.g., atrial fibrillation, premature ventricular contractions)
Yes
No
Do you have chronic heart failure?
Yes
No
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?
Yes
No
Do you currently have High Blood Pressure?
* must provide value
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer no if you are not currently taking any medications)
Yes
No
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer yes if you do not know your resting blood pressure)
Yes
No
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes
* must provide value
Yes
No
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?
Yes
No
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.
Yes
No
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, or the sensation in your toes/feet?
Yes
No
Do you have other metabolic conditions (such as pregnancy related diabetes, chronic kidney disease, or liver problems)?
Yes
No
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?
Yes
No
Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer's Disease, Dementia, Depression, Anxiety Disorders, Eating Disorders, Psychotic Disorders, Intellectual Disability, Down Syndrome
* must provide value
Yes
No
Please provide diagnosis and medications if you answered yes:
* must provide value
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
Yes
No
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure
* must provide value
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer no if you are not currently taking any medications)
Yes
No
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?
Yes
No
If asthmatic, do you currently have symptoms of chest tightness, wheezing, labored breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?
Yes
No
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?
Yes
No
Do you have a spinal cord injury? This includes Tetraplegia and Paraplegia
* must provide value
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer no if you are not currently taking medications or other treatments)
Yes
No
Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?
Yes
No
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)
Yes
No
Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event.
* must provide value
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer no if you are not currently taking any medications or other treatments)
Yes
No
Do you have any impairment in walking or mobility?
Yes
No
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?
Yes
No
Do you have any other medical conditions not listed above or do you have two or more medical conditions listed?
* must provide value
Yes
No
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?
* must provide value
Yes
No
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?
* must provide value
Yes
No
Do you currently live with two or more medical conditions?
* must provide value
Yes
No
Please list any and all conditions here with medications:
* must provide value
When did you enter menopause?
* must provide value
Are you currently taking hormone replacements?
* must provide value
Yes
No
Please tell us your medications prescribed for your menopause:
* must provide value
Please check if you are you experiencing any of the following symptoms:
* must provide value
Have you ever given birth?
* must provide value
Yes
No
If you said yes to the above question, please tell us the type of delivery:
C-section
Vaginal
Please tell us what supplements you are taking daily:
* must provide value
Please tell us your fitness/wellness goals for participating in this program:
* must provide value
Signature:
* must provide value