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Health History Form
Date: __________________
Last Name: ________________________________________ First Name:
_____________________________________________
Address:
______________________________________________________________________________________________________
City: ____________________________________________ Zip Code:
________________________ Phone: _________________
Date of Birth: ________________________ Age: _________ Gender:
Male_______ Female______
Regular physical activity is safe for most people. However, some
individuals should check with their doctor before starting an exercise program. To help us
determine if you should consult with your doctor before starting to exercise with the
Fitness Trainers, please read the following questions carefully and answer each one
honestly. All information will be kept confidential. Please check Yes or No
to the following questions:
YES NO
___ ___
1. Are you a male over 45 years of age
___ ___
2. Are you a female over 55 years of age
___ ___
3. Has anyone in your immediate family had a heart attack,
stroke, or heart
disease >
55
___ ___
4. Are you currently smoking?
If yes, how long have you been smoking? _______ How many packs a day? _______
___ ___
5. Have you ever smoked? If yes How long? ________ Average packs
a day? _________
___ ___
6. Have you ever been told you have high lipids or high
cholesterol readings?
___ ___
7. Are you a diabetic?
___ ___
8. Are you currently exercising less than one hour a week? Please
list you activities:
___ ___
9. Have you ever been diagnosed with high blood pressure
___ ___ 10.Do you have a
history of heart problems or ever been told you have a heart
murmur?
___ ___ 11.Do
you feel pain or discomfort in your chest at rest or with exercise
___ ___ 12.Do
you ever lose consciousness or have you ever lost your balance due to dizziness?
___ ___ 13.Do
you ever experience unusual fatigue or shortness of breath with normal
daily
activities
___ ___ 14.Do
you have any type of pulmonary or breathing problems (asthma, COPD,
emphysima)
___ ___
15.Have you ever had a stroke
___ ___ 16.Do
you have epilepsy or have you ever had a seizure?
___ ___ 17.Is
there family history of diabetes, high blood pressure, or cancer?
___ ___
18.Are you currently pregnant?
___ ___
19.Are being treated for a bone or joint problem that restricts
physical activity?
___ ___
20.When was your last medical physical from your physician?
_______________________________
___ ___ 21.Do
you ever feel your heart race uncontrollably or "skip" a beat?
___ ___ 22.Do
you have an unusual shortness of breath at rest or with mild exertion?
___ ___
23.Are you currently taking any supplements or medications? I f
yes please list the
the name of the medications/supplements and reason for taking them:
________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Emergency contact name:
________________________________________________________________________________________
Phone #: __(
)___________-_____________ ____________________________________
Relationship________________________________________________________
| STAFF USE ONLY:
___________________ Resting HR:________
Resting BP: _________ Cleared to exercise ________
Not cleared to exercise_________ Reason _____________________________
STAFF SIGNATURE_______________________________________________DATE:___________________________ |
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