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Get ACSM HEALTH STATUS QUESTIONNAIRE - YMCA Of The Fox Cities

Onfidential. NAME: ADDRESS: CITY: STATE: ZIP: DATE OF BIRTH: / / Daytime Phone: WITH DISEASE (physician approval needed if any checked) Do you have any personal history of coronary or atherosclerotic disease? Any personal history of metabolic disease (thyroid, renal, liver)? Have you had diabetes for less than 15 yea.

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