Healthy History Form

Your Name

Your Mobile Number

History of hearth problems,chest pain or stroke

Elevated Blood Pressure

Any Chronic Illness or Condition

Difficulty with physical exercise

Recent Surgery ( e.g. General Operation,C-Section( Cesarean delivery)

History of breathing or lung problems e.g. asthmatic

Muscle,Joint or Back Disorder  or any previous injury still affecting you

Cigarette Smoking Habit

Diabetic

History of heart problems in immediate family

Any Additional Information you would like to add (Comments,Questions,Suggestions)