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A Primary Care Gym® Health Intake Screening
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Name
*
Email
*
Phone Number
*
Has a physician ever told you that you have any of the following? Check ALL that apply.
Coronary Heart Disease
Heart Attack
Stroke
High Blood Pressure
Irregular Heart Rhythm
Heart Valve Problems
Diabetes
Angina
Heart Murmur
Anemia
Asthma, Emphysema, COPD or Other Lung Disease
Peripheral Artery Disease or Claudication
Have you experienced any of the following in the past 90 days?
Select YES or NO.
Chest Pain With Exertion
*
Yes
No
Shortness of Breath With Exertion
*
Yes
No
Shortness of Breath While Lying Flat
*
Yes
No
Heart Palpitations
*
Yes
No
Heart Attack
*
Yes
No
Heart Failure
*
Yes
No
Dizziness Upon Standing or Getting Out of Bed
*
Yes
No
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