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Health History Questionnaire

 

Please fill in the forms fields below: All fields are mandatory.

Typy in N/A if any field is inapplicable. (Your information is confidential)

 

Personal Information
Name Date of Birth Age
Full Address Email  
Home Phone Work Phone Cell Phone
Employer Occupation  

 

In case of emergency, please notify;
Name Relationship
Full Address Email
Home Phone Work Phone Cell Phone

 

Medical Information - all mandatory
Physician Phone
 
Are you under the care of a physician, chiropractor, or other health care professional for any reason? If yes, list reason: Yes No
Reason:
 
Are you taking any medications? If yes, complete the following: Yes No
Type: Dosage: Reason:
 
Please list any allergies you have:
Has your doctor ever said your blood pressure was too high? Yes No
Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise? Yes No
Are you over the age of 65? Yes No
Are you unaccustomed to vigorous exercise? Yes No
Is there any reason not mentioned why you should not follow a regular exercise program? If yes, please explain: Yes No
Have you recently experienced any chest pain associated with either exercise or stress? If yes, please explain: Yes No

Smoking:
Please check the box that describes your current habits:
Non-user of former user; Date quit:
Cigar and/or pipe
15 or less cigarettes per day
16 to 25 cigarettes per day
26 to 35 cigarettes per day
More than 35 cigarettes per day


Family & Personal Medical History
If there is family history for any condition, please check the box to the left. If you are personally experiencing any of these conditions, ll the information in on the line to the right.
Asthma:
Respiratory/Pulmonary Conditions:
Diabetes: Type I: Type II: How Long?
Epilepsy: Petite Mal: Grand Mal: Other:
Osteoporosis:        
 

Lifestyle and dietary factors:
Occupational Stress Level: Low Medium High
Energy Level: Low Medium High
Caffeine Intake/Daily: Colds Per Year:  
Alcohol Intake/Weekly: Anemia:  
Gastrointestinal Disorder: Hypoglycemia:  
Thyroid Disorder: Pre/Postnatal:  
 

Cardiovascular:
High Blood Pressure:  
Hypertension: Heart Disease:  
High Cholesterol: Heart Attack:  
Hyperlipidemia: Angina:  
Stroke: Gout:  
 

Musculoskeletal Information:
Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort:
Head/Neck: Shoulder/Clavicle:  
Arm/Elbow: Wrist/Hand:  
Upper Back: Lower Back:  
Hip/Pelvis: Thigh/Knee:  
Arthritis: Hernia:  
Surgeries: Other:  
 

Nutritional Information:
Are you on any specifc food/diet plan at this time? Yes No If yes, please list:
Do you take dietary supplements? Yes No If yes, please list:
Do you experience any frequent weight fluctuations? Yes No    
Have you experienced a recent weight gain or loss? Yes No If yes, list change:
      And over how long?
How many beverages do you consume per day that contain caffeine?
How would you describe your current nutritional habits?
Other food/nutritional issues you want to include: (food allergies, mealtimes, etc.)

 

Work & Exercise Habits
Please check the box that best describes your work and exercise Habits.
Intense occupational and recreational exertion
Moderate occupational and recreational exertion
Sedentary occupational and intense recreational exertion
Sedentary occupational and moderate recreational exertion
Sedentary occupational and light recreational exertion
Complete lack of all exertion
 

To what degree do you perceive your environment as stressful?
Work: Minimal Moderate Average Extreme
Home: Minimal Moderate Average Extreme
Do you work more than 40 hours a week? Yes          No
Please make any other comments you feel are pertinent to your exercise program:

 

Referral Information
How did you hear about us?

 

I agree & sign. *
(This checkbox contitutes your signature and is mandatory. If you do not wish to sign, please call (301) 455 - 3347.)

 

 
 

 

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