Health & Medical
Questionnaire

Please fill out the form below:

Name *
Name
Address
Address
Name
Personal Physician Phone Number
Personal Physician Fax number
Rheumatic Fever
Have you had OR do you presently have the following condition? Check yes or no.
Recent Operation
Have you had OR do you presently have the following condition? Check yes or no.
Edema (swelling of ankles)
Have you had OR do you presently have the following condition? Check yes or no.
High Blood Pressure
Have you had OR do you presently have the following condition? Check yes or no.
Injury to back or knees
Have you had OR do you presently have the following condition? Check yes or no.
Low Blood Pressure
Have you had OR do you presently have the following condition? Check yes or no.
Seizures
Have you had OR do you presently have the following condition? Check yes or no.
Lung Disease
Have you had OR do you presently have the following condition? Check yes or no.
Heart Attack
Have you had OR do you presently have the following condition? Check yes or no.
Fainting or Dizziness with or without physical exertion
Have you had OR do you presently have the following condition? Check yes or no.
Diabetes
Have you had OR do you presently have the following condition? Check yes or no.
High Cholesterol
Have you had OR do you presently have the following condition? Check yes or no.
Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack) nocturnal dyspnea (shortness of breath at night)
Have you had OR do you presently have the following condition? Check yes or no.
Shortness of breath at rest or with mild exertion
Have you had OR do you presently have the following condition? Check yes or no.
Chest pains
Have you had OR do you presently have the following condition? Check yes or no.
Palpitations or tachycardia (unusually strong or rapid heartbeat)
Have you had OR do you presently have the following condition? Check yes or no.
Intermitten Claudication (calf cramping)
Have you had OR do you presently have the following condition? Check yes or no.
Pain, discomfort in the chest, neck, jaw, arms, or other areas with or without physical exertion
Have you had OR do you presently have the following condition? Check yes or no.
Known Heart murmur
Have you had OR do you presently have the following condition? Check yes or no.
Unusual fatigue or shortness of breath with usual activities
Have you had OR do you presently have the following condition? Check yes or no.
Temporary loss of visual acuity or speech, or short-term numbness or weakness in one side, arm, or leg of
Have you had OR do you presently have the following condition? Check yes or no.
Other
Have you had OR do you presently have the following condition? Check yes or no.
 
 

FAMILY MEDICAL HISTORY

Heart Arrhythmia
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Heart Attack
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Heart Operation
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Congenital Heart Disease
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Premature death before age 50
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Significant disability secondary to a heart condition
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Marfan Syndrome
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
High Blood Pressure
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
High Cholesterol
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Diabetes
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
 
 

ACTIVITY HISTORY

Are you presently employed?
Have you ever worked with a personal trainer before?
Do you participate in a regular exercise program at this time?
Can you currently walk 4 miles birskley without fatigue?
Have you ever performed resistance training exercised in the past?
Do you smoke?