Health & Medical Questionnaire
Date *
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Name *
Your answer
Date of birth *
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Address *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Email Address
Your answer
In case of emergency, whom may we contact?
Name *
Your answer
Relationship *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Personal Physician Name, Phone & Fax *
Your answer
Present & Past History
Have you ever had OR do you presently have any of the following conditions? Check option if yes. Leave blank if not.
Rheumatic fever?
Recent operation?
Edema? (swelling of ankles)
High blood pressure?
Injury to back or knees?
Low blood pressure?
Seizures?
Lung disease?
Heart attack?
Fainting or dizziness without physical exertion?
Diabetes?
High cholesterol?
Orthopnea (the need to sit up to breath comfortably) or paroxysmal(sudden, unexpected attack) nocturnal dyspnea? (shortness of breath at night)
Shortness of breath at rest or with mid exertion? *
Required
Chest pains?
Palpitations or tachycardia? (unusually strong or rapid heartbeat)
Intermittent claudication (calf cramping)?
Pain, discomfort in the chest, neck, jaw, arms, or other areas with or without physical exertion?
Known heart murmur?
Unusual fatigue or shortness of breath with usual activities?
Temporary loss of visual activity or speech or short term numbness or weakness in one side, arm, or leg of your body?
Other
Your answer
Family History
Check yes is so.
Heart arrhythmia
Hearth attack
Heart operation
Congenital heart disease
Premature death before the age 50
Significant disability secondary to heart condition
Marfan syndrome
High blood pressure
High cholesterol
Diabetes
Other major illness
Explain checked items
Your answer
Active History
Why are you enrolling in this program? (be specific) *
Your answer
Are you currently employed? *
Required
What is you present occupation position? *
Your answer
Name of company?
Your answer
Have you ever worked with a personal trainer before?
Date of your last physical examination performed by a physician *
MM
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Do you participate in a regular excersise program? If yes describe briefly.
Your answer
Can you currently walk 4 miles briskly without fatigue?
Have you ever performed resistance training exercises in the past?
Do you have injuries (bone or muscle disabilities) that may interfere with exercising? If yes, briefly describe:
Your answer
Do you smoke?
If yes, how much per day? What age did you start?
Your answer
What is your body weight now?
Your answer
What was your weight a year ago?
Your answer
Do you follow or have you recently followed any specific dietary intake plan, and in general how do you feel about your nutritional habits?
Your answer
List of medications you are presently taking?
Your answer
List your Personal health and fitness objectives.
Your answer
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