Медицинская справка для занятий спортом в студии

(The questionnaire is worded in a male language for convenience, but it is also intended for a female)

Part I: Medical Questionnaire

Please read the questions below thoroughly and answer any questions honestly by marking in the appropriate box.

1. Did your doctor tell you that you have heart disease?

Yes

2. If you have chest pain?

(please mark your answer in any of the options below)

(do not fill out if this is not relevant to you)

(A) While resting

(B) During daily routine activities

3. During the past year

(please mark your answer in any of the options below)

(A) Did you lose your balance due to dizziness?