Health & MedicalQuestionnaire Please fill out the form below: Date Name * First Name Last Name Date of Birth 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!