GUILT PROGRAM MEDICAL QUESTIONAIRE

         There are now additional ways of sending this questionaire 
     back to me.  In addition to saving it as a .txt file, to send it 
     as a .txt format attachment; and, copy it from the screen, to 
     paste into an e-mail; I'm adding links which will automatically 
     insert the questions into the body of your e-mail.  These e-mail 
     links will be in red.



     I have no desire to place anyone's health or life at risk.  
It is in your own best interest to provide honest and accurate 
medical information to me; and, to the physician who will do 
your medical exam.  While some conditions might cause me to 
decline your case, either alone or combined with your overall 
medical picture, do NOT be tempted to hide any such condition.  
NOTHING you could have done is worth your life!  I will make 
every effort to make provisions for any medical problems you 
might have; but, I MUST know in advance what these problems 
are. If necessary, I will arrange to have an EMT or doctor 
on stand-by, if your situations seems to call for doing so.

     Name:  

     Date of birth: 

     Height: 

     Weight: 

     Please answer "Yes" or "No" to each of the following.  
If you answer "Yes," please give complete details, including:  
dates of diagnosis, treatment and its results, effects it has 
upon your daily living and ability to engage in exercise, long-
term prognosis, etc.

     Have you ever been diagnosed with any of the following:

      1) Heart disease

      2) Heart problems of any sort 

      3) Stroke

      4) Stroke precursors 

      5) Aneurism  

      6) Embolism

      7) High blood pressure
     
      8) High or low blood sugar

      9) Resperatory problems of any sort 

     10) Cancer 

     11) HIV 

     12) Bleeding or clotting disorders 

     13) Any mental disorder

     14) Head injury 

     15) Epilepsy 

     16) Seizures, convulsions, or unexplained dizziness 

     17) Drug  or food allergies 

     18) Alcoholism or other drug dependantcy

     19) Spinal injuries 

     20) Hernia 

     21) Have you ever attempted suicide?

     22) Any serious or chronic condition not listed above?

 Medical, Part 1 of 2

     Please answer the following:

      1) When was the date of your last medical exam?

      2) Were any problems found on this exam?

      3) Was an exercise cardiology test performed?

      4) Have you ever had such a test performed, either for medical 
         reasons or in order to participate in a sport, health club 
         or fitness center activities, etc.?

      5) If so, how long ago and what were the results of that test?

      6) If you are female, could you be pregnant?

      7) List all exercise related activities which you engage in. 

      8) List any non-prescription medications which you routinely take, 
          and their purpose.

      9) If you smoke, approx. how many cigarettes per day?  If you 
          do NOT smoke, are you extremely sensitive to cigarette smoke?

     10) If you drink alcohol, approx. how many drinks per week?

     11) List any (usually prescription) medications you MUST take, 
           including the reason.

     12) List any disabilities or impairments you might have.

     13) Do you have full "range of motion?"

     14) List all hospitalizations, including their cause and duration.

     15) List all out patient proceedure performed upon you within the 
         past 10 years, including their cause and outcome.

     16) List all visits to a physician in the past 5 years, including 
         their cause and outcome.

     17) Do you have any reason to believe that engaging in strenuous 
         physical exertion could pose a risk to your heath or your life?  
         If so, please explain.

     18) What medical accomodations or precautions do you feel I 
         should insure are in place, if I decide to accept your case?

     19) Is there anything which was not asked on this form; but, which 
         I should know about in order to best protect your safety?


          Again, I would like to emphasize that I will not refuse to 
     accept your case based solely upon your answers to this questionaire.  
     It is far more likely that, if I decide to agree to help you (based 
     upon the total picture) I'll simply go out of my way to take any 
     precautionary measures which are needed to insure that your health 
     and well-being are protected while you are in my custody.  Please 
     take a few minutes to go back over your answers, adding any information 
     which you might have omitted the first time through.  Your health is 
     ulimately your own responsibility -- I can only gaurd against problems 
     which I am able to anticipate, based upon the information you, and your 
     doctor, provide.


     To the best of your knowledge, have you answered this questionaire 
     honestly and thoroughly? Please delete thw one which does not apply: 
     Yes  No 


Signature: 
Date: 


 Medical, Part 2 of 2