Zumba Medical History Form
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Please check the conditions if they apply to you or to any members of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
None
Please check if you have ever been diagnosed with the followings:
High blood pressure
Diabetes
Broken bone
Heart problems
Kidney problems
Muscle injuries
Head injuries
Cancer
Arthritis
Hernia
Lung problems or asthma
Thyroid issues
Blood disorder
Allergies
Ostereoposis
Fibryomyalagia or ME
MS
Depression
None
Please check if you're currently experiencing any of the following symptoms:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Back, neck or shoudler ache or pain
Stress
Sore throat
Thyroid issues (under or over active or other)
None
Are you currently taking any prescribed medication?
Yes
No
Are you currently taking any over the counter medicine?
Yes
No
Please give details
Have you had any surgeries in the past 5 years?
Yes
No
Please give details
Do you have a history of fainting
Never
Rarely
Yes
No but sometimes I feel dizzy
Do you ever get chest pain, tight chest or difficulty breathing during cardio training?
Yes
No
Rarely
If you have contraindications to cardio exercise due to health reasons, has your doctor cleared you for this kind of cardio interval training?
Yes
No
Not Sure
N/A
If you are on any kind of special diets please give details.
Low carb, fasting, meal plans, low calorie, etc.
Do you use or do you have history of using tobacco?
Yes
No
Rarely
Are you pregnant or have given birth in the last 6 months?
Yes
No
Not Sure
N/A
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Your Occupation
Have you ever done Zumba or similar classes previously?
Yes
Never
occasionally
Please select the option best describes your current activity levels
Highly active (heavy manual labour occupation, sports person, daily training and cardio)
Moderately active (exercise 3-4 times a week outside of daily activities)
Moderate-low activity levels (1-2 times a week of exercise)
Fairly sedentary, little exercise
Other
Where did you hear about Zumba class?
Submit
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