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Strength & Conditioning Past Medical History Form
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* Indicates required question
Date
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MM
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DD
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YYYY
Name
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Your answer
Date of Birth
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MM
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DD
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YYYY
Medical History: Have you had OR do you presently have any of the following:
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COVID-19
Recent operation
Edema (swelling of ankles)
High Blood Pressure
Low Blood Pressure
Injury/surgery of neck, back, shoulder, elbow, hand, hip, knee, leg ankle, foot
Seizures
Lung Disease
Heart Attack
Dizziness or fainting
Diabetes
High Cholesterol
Shortness of Breath
Chest Pain
Palpitations or Tachycardia (unusually strong or rapid heartbeat)
Pain, discomfort in the chest, neck, jaw, arms, or other areas with or without physical exertion
Unusual fatigue or shortness of breath with usual activities
Temporary loss of visual acuity or speech, or short-term numbness or weakness in one side
Other
None
Required
Explain checked items above:
Your answer
Family Medical History: Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
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Heart arrhythmia
Heart Attack
Heart Operation
Heart Disease
Premature death before the age of 50
Significant disability secondary to a heart condition
Marfan Syndrome
High Blood Pressure
High Cholesterol
Diabetes
Other major illness
None
Required
Explain checked items above:
Your answer
How were you referred to this program?
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Your answer
Why are you enrolling in this program? What are your goals?
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Your answer
What is your present occupational position, if any?
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Your answer
Have you worked with a Strength and Conditioning Specialist in the past?
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Yes
No
Date of your last physical exam by a physician
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MM
/
DD
/
YYYY
Do you participate in a regular exercise program at this time?
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Yes
No
If yes, please briefly describe
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Your answer
Do you have any injuries that may interfere with exercising?
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Yes
No
If yes, please describe
Your answer
List any medications you are presently taking
*
Your answer
By my signature below, I certify that the information I have provided above is complete, accurate and truthful to the best of my knowledge. By typing my name below, I am providing my electronic signature acknowledging the above policies (If the patient is less than 18 years of age, the parent or legal guardian must type both their child’s name as well as their name below. By signing below, parents are signing on behalf of their child but are also agreeing that they are personally responsible for the treatment provided to their child under this Agreement.) *
*
Your answer
Date
*
MM
/
DD
/
YYYY
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