Health/Medical Questionnaire Please enable JavaScript in your browser to complete this form.Date:Name *FirstLastDate of Birth:AddressPhone (H)Phone (W)Email Address *Emergency Contact Name:RelationshipPhone (H)Phone (W)Personal Physician's Name *FirstLastPhoneFaxHave you had OR do you presently have any of the following conditions? (Check if yes.)Rheumatic feverRecent operationEdema (swelling of ankles)High blood pressureInjury to back or kneesLow blood pressureseizuresLung diseaseHeart attackFainting or dizziness with or without physical exertionDiabetesHigh cholesterolOrthopnea (the need to sit up to breath properly) or paroxysmal (sudden, unexpected attack) nocturnal dyspnea (shortness of breath at night)Shortness of breath at rest or with mild exertionChest painsPalpitations 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 exertionKnown heart murmurUnusual fatigue or shortness of breath with usual activitiesTemporary loss of visual acuity or speech, or short-term numbness or weakness in one side, arm, or leg of your bodyOtherHave any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes) In addition, please identify at what age the condition occurred.Heart ArrhythmiaHeart AttackHeart operationCongenital heart diseasePremature death before age 50Significant disability secondary to a heart conditionMarfan SyndromeHigh blood pressureHigh cholesterolDiabetesOther major illnessExplain checked items1. How were you referred to this program? (Please be specific.)2. Why are you enrolling in this program? (Please be specific.)3. Are you presently employed?YesNo4. What is your present occupational position?5. Name of company:6. Have you ever worked with a personal trainer before?YesNo7. Date of your last physical examination performed by a physician:8. Do you participate in a regular exercise program at this time?YesNoIf yes, briefly describe:9. Can you currently walk 4 miles briskly without fatigue?YesNo10 Have you ever performed resistance training exercises in the past?YesNo11. Do you have injuries (bone or muscle disabilities) that may interfere with exercising?YesNoIf yes, briefly describe:12. Do you smoke?YesNoIf yes, how much per day and what was your age when you started?13. What is your body weight now?What was it one year ago?At age 21?14. Do you follow or have you recently followed any specific dietary intake plan, and in general how do you feel about your nutritional habits?15. List the medications you are presently taking.16. List in order your personal health and fitness objectives.Submit
