Name:
Address:
Phone:
e-mail:
History of symptoms:
Do you have asthma? Y N
Do you have shortness of breath with mild exercise? Y N
Do you become dizzy with exercise? Y N
Have you ever lost consciousness with exercise? Y N
Have you been told by a physician that you have heart trouble? Y N
Do you have, or have you had, chest pain when exercising? Y N
Do you get palpitations or rapid heart rate with exercise? Y N
Do you get wheezing with exercise, or immediately after exercise? Y N
Medications and Supplementation:
Do you currently use inhalers? Y N
Are you currently taking any prescription medications? Y N
Are you allergic to any medications? Y N
Do you know of any other reason why you should not participate in this test?
I have read, understood this questionnaire and any other questionnaires provided. Any questions I had were answered to my satisfaction. I also understand that this is an elective test, and information regarding diagnosis of underlying pathology must be followed up with my personal physician.
Signature:
Date:
Witness: