Medical History To provide information regarding current health and fitness status, complete the items below.

Ask for assistance from your parents or guardians if needed. Part I: Personal Information Name: _________Alexandra M Valencia_____________________ Age: ________________16_______________________________ Height _5'5_______ Weight ___137_____ Part II: Health Status (If you answer yes to any of the below, please explain) 1. Have you ever been diagnosed with a heart condition? no 2. Do you frequently have pain in your chest? no 3. Do you suffer from severe dizziness? I am iron defficient and if i chose not to take my medication its possible. 4. Do you have any orthopedic problems? no 5. Is there any other reason that would prohibit you from participating in any physical activities? no 6. Please indicate your perception of your present medical condition _____ Excellent ___xxx__ Good _____ Fair _____ Poor Part III. Physical Activities 1. Have you ever been told that you should not engage in a specific type of exercise? no 2. Please list any activities or sports that you participate in on a weekly basis. walking often. 3. Indicate 1-3 activities you enjoy: a. b. c. d. e. f. g. h. i. j. 4. 5. a. X b. c. d. e. f. Walking X Jogging Cycling Skating X Dancing Swimming Rowing Rope jumping Boxing Stationary machines X Do you prefer to work indoors or outdoors? indoors What is your primary goal for this course? Improve health and fitness Gain or lose weight Body building; adding muscle Improve athletic performance Increase physical activity level. Earn a credit