Health History Questionnaire Name Date of Birth (DD/MM/YYYY) Address Post Code Email Phone Number In case of emergency, please notify: Name Date of Birth (DD/MM/YYYY) Address Post Code Phone Number Relationship Medical Information Physician Phone Are you under the care of a physician, chiropractor, or other health care professional for any reason? YES NO If yes, list reason: Are you taking any medications? YES NO If yes, please complete the following: Type | Dosage/Frequency | Reason for taking: Please list any allergies 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? YES NO If yes, please explain Have you recently experienced any chest pain associated with either exercise or stress? YES NO If yes, please explain Smoking Please check the box that describes your current habits Non-user or former userCigar and/or pipe15 or less cigarettes per day16 to 25 cigarettes per day26 to 35 cigarettes per dayMore than 35 cigarettes per day Family & Personal Medical History If there is family history for any condition, please check the box Asthma Respiratory/Pulmonary Conditions Diabetes Epilepsy Osteoporosis If you are personally experiencing any of these conditions, please let us know which condition, what type, and how how long you have had it below. Lifestyle & Dietary Factors Occupational Stress Level: LOW MEDIUM HIGH Energy Level: LOW MEDIUM HIGH Daily caffeine intake? Weekly alcohol intake? Colds per year? If applicable, please select the appropriate option(s): Gastrointestinal Disorder Hypoglycemia Thyroid Disorder Pre/Postnatal Do you have any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort: Neck/back Upper Back Shoulder/Clavicle Arm/Elbow Wrist/Hand Lower Back Hip/Pelvis Thigh/Knee Arthritis Hernia Surgeries Other Please go into as much detail as you can about the affected area(s). Nutritional Information Are you on any specific 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 time period How would you describe your current nutritional habits? Other food/nutritional issues you want to include (food allergies, mealtimes, etc.) 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 work environment as stressful? Minimal Moderate Average Extremely To what degree do you perceive your home environment as stressful? Minimal Moderate Average Extremely Do you work more than 40 hours per week? YES NO Please make any other comments you feel are pertinent to your exercise program. submit continue back to documents hub
