WILCOX Health History Questionnaire
Please answer the following questions to the best of your ability. For the following questions, unless otherwise indicated, select the single best choice for each question. As is customary, all of your responses are completely confidential and may only be used in group summaries and/ or reports. All information collected is subject to the Privacy Act of 1974. If you have any physical handicaps or limitations that would require special assistance with this questionnaire, please let your trainer know. This form is in accordance with the American College of Sports Medicine guidelines for risk stratification when followed correctly by your trainer. All trainers of Wilcox Wellness & Fitness are certified with a national organization in order to use these forms correctly.
Full Name (First, Last) *
Your answer
Your GYM location: *
Height (inches) *
Your answer
Weight (lbs) *
Your answer
Gender *
Age *
Your answer
Emergency Contact *
Your answer
Emergency Contact Phone *
Your answer
Personal Physician *
Your answer
Physician Phone *
Your answer
1. Have you ever had a definite or suspected heart attack or stroke? *
2. Have you ever had a coronary bypass surgery or any other type of heart surgery? *
3. Do you have any other cardiovascular or pulmonary (lung) disease? *
4. Do you have a history of: diabetes, thyroid, kidney, liver diseases? *
5. Have you ever been told by a health professional that you have had an abnormal resting or exercise (treadmill) electrocardiogram (EKG)? *
6. If you answered YES to any of Questions 1-5, please describe:
Your answer
7. Do you currently have any of the following? (Check all that apply) *
Required
8. Have you discussed any of the above with your personal physician? *
9. Are you pregnant or is it likely that you could be pregnant at this time? *
If you are pregnant - what is your expected due date?
Your answer
10. Have you had surgery or been diagnosed with any diseases in the past 6 months? *
If yes, please list date and surgery/disease:
Your answer
11. Have you had high blood cholesterol or abnormal lipids within the past 12 months, or are you taking medication to control your lipids? *
12. Do you currently smoke cigarettes or have quit within the past 12 months? *
13. Have your father or brother(s) had heart disease prior to age 55 or mother or sister(s) had heart disease prior to age 65? *
14. Within the past 12 months, has a health professional told you that you have high blood pressure (systolic >140 OR diastolic >90)? *
15. Currently, do you have high blood pressure or within the past 12 months, have you taken any medicines to control your blood pressure? *
16. Have you ever been told by a health professional that you have a fasting blood glucose greater than or equal to 110 mg/dl? *
17. If you have answered YES to any of Questions 7-16, please describe in detail:
Your answer
18. Are you currently under any treatment for blood clots? *
19. Do you have problems with bones, joints, or muscles that may be aggravated with exercise? Including stiffness in back, knees, shoulders? *
Please explain...
Your answer
20. Do you have any back or neck problems? *
Please explain...
Your answer
21. Have you been told by a health professional that you should not exercise? *
22. Are you currently being treated for any other medical condition by a physician? *
If you are currently being treated for any other medical condition by a physician, please explain...
Your answer
23. Are there any other conditions (mitral valve prolapse, epilepsy, history of rheumatic fever, asthma, cancer, hepatitis, etc.) that may hinder your ability to exercise? *
Please explain...
Your answer
24. During the past six months, have you experienced any unexplained weight loss or gain (greater than ten pounds for no known reason)? *
Please explain...
Your answer
Please list any medications that you take
Your answer
I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in the development of my fitness and wellness program. I understand that certain medical or physical conditions which are known to me, but that I do not disclose to my trainer, may result in serious injury to me. If any of the above conditions change, I will immediately inform my trainer of those changes. I, knowingly and willingly, assume all risks of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the attached questionnaire. I also understand that in order to properly risk stratify my Health History Questionnaire, my trainer should have a minimum national certification as a personal trainer. My trainer also verbally will explain this statement to me to my understanding. *
Required
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