Health History Questionnaire

Contact Information

Please answer the following questions regarding your contact information:

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Medical Information

Please answer the following questions regarding your medical history:

Physician (Primary):

Physician (Primary) Phone Number:

Are you under the care of a physician, chiropractor, physical therapist or other health care professional for any reason?

Yes
No
Prefer not to state

If yes, please list reason:

Are you currently taking any medications?

Yes
No
Prefer not to state

If yes, please list the type of medication, the dosage/frequency, and the reason for taking:

Please list any allergies (including food and/or chemical allergies):

Has your doctor ever said your blood pressure was too high? *

Yes
No

Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise? *

Yes
No

Are you unaccustomed to vigorous exercise? *

Yes
No

Is there any reason not mentioned why you should not follow a regular exercise program? *

Yes
No

If yes, please explain:

Have you recently experienced any chest pain associated with either exercise or stress? *

Yes
No

If yes, please explain:

If there is personal history for any condition, please check the box.

Smoking Information

Please answer the following questions regarding your smoking history:

Please check the box that describes your current habits:

Non-user or former-user
Cigar and/or pipe
15 or less cigarettes daily
15 or more cigarettes daily

Personal Health History

Please answer the following questions regarding your personal medical history:

Please describe your overall level of work related stress:

Low
Medium
High
Prefer not to state

Please describe your overall level of personal stress:

Low
Medium
High
Prefer not to state

Please describe your overall level of energy:

Low
Medium
High
Prefer not to state

Please check the box that best describes your work and exercise habits.

Intense occupational and recreational exertion
Moderate occupational and recreational exertion
Sedentary occupational and intense recreational exertion
Sedentary occupational and moderate recreational exertion
Sedentary occupational and light recreational exertion
Complete lack of all exertion

Please describe your overall level of caffeine intake:

Please describe your overall level of alcohol intake:

None
Low (0-2 drinks daily, 1-2x weekly)
Medium (2 or less drinks daily for 3 days of the week)
High (greater than 5 drinks daily or 15 drinks weekly)
Prefer not to state

Musculoskeletal Health History

Please answer the following questions regarding your personal musculoskeletal conditions history:

Please describe any past or current musculoskeletal conditions you have incurred such as muscle strains, joint sprains, bone fractures, hernias, or general discomfort:

Please describe any musculoskeletal procedures you have incurred, including surgeries or joint replacements:

Nutrition History

Please answer the following questions regarding your personal dietary habits:

Are you on any specific food/diet plan at this time?

Yes
No
Prefer not to state

Emergency high? If

If yes, please list:

Do you take dietary supplements?

Yes
No
Prefer not to state

If yes, please list:

Do you experience any frequent weight fluctuations?

Yes
No
Prefer not to state

Have you experienced a recent weight gain or loss?

Yes
No
Prefer not to state

If known, please describe your current nutritional habits, including caloric intake, macronutrient ratios, meal frequency, and/or dietary preferences:

Your Signature *

Clear Signature

By signing above, I hereby declare that the information provided is true and correct, and that misrepresentation or omission of health related issues may disqualify me from safely participating in an exercise program.

Date *