Everfit Motion LLC
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Home
Services
Success Stories
About
Everfit Motion LLC
Contact
Health & Medical
Questionnaire
Please fill out the form below:
Date
Name
*
Name
First Name
Last Name
Date of Birth
Address
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
Work Phone
Email Address
*
In case of emergency, whom may we contact?
Relationship
Emergency Contact Number
Personal Physician
Name
Phone
Personal Physician Phone Number
Fax
Personal Physician Fax number
Rheumatic Fever
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Recent Operation
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Edema (swelling of ankles)
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
High Blood Pressure
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Injury to back or knees
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Low Blood Pressure
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Seizures
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Lung Disease
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Heart Attack
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Fainting or Dizziness with or without physical exertion
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Diabetes
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
High Cholesterol
Have you had OR do you presently have the following condition? Check yes or no.
Yes
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.
Yes
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.
Yes
No
Chest pains
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Palpitations or tachycardia (unusually strong or rapid heartbeat)
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Intermitten Claudication (calf cramping)
Have you had OR do you presently have the following condition? Check yes or no.
Yes
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.
Yes
No
Known Heart murmur
Have you had OR do you presently have the following condition? Check yes or no.
Yes
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.
Yes
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.
Yes
No
Other
Have you had OR do you presently have the following condition? Check yes or no.
Yes
No
Thank you!
FAMILY MEDICAL HISTORY
Heart Arrhythmia
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Yes
No
Heart Attack
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Yes
No
Heart Operation
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Yes
No
Congenital Heart Disease
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Yes
No
Premature death before age 50
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Yes
No
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.)
Yes
No
Marfan Syndrome
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Yes
No
High Blood Pressure
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Yes
No
High Cholesterol
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Yes
No
Diabetes
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
Yes
No
Other major illness...
Explain checked items:
Thank you!
ACTIVITY HISTORY
How were you referred to this program?
Why are you enrolling in this program?
Are you presently employed?
Yes
No
What is your present occupational position?
Name of company
Have you ever worked with a personal trainer before?
Yes
No
Date of your last physical examination performed by a physician:
Do you participate in a regular exercise program at this time?
Yes
No
Can you currently walk 4 miles birskley without fatigue?
Yes
No
Have you ever performed resistance training exercised in the past?
Yes
No
Do you smoke?
Yes
No
If you smoke, how many packs per day?
What is your body weight now?
What was it a year ago?
Do you follow or have you recently followed any specific dietary intake plan, and in general how do you feel about your nutritional habits?
List any medications you are currently taking:
List in order your personal health and fitness objectives:
Thank you!