HEALTH HISTORY QUESTIONNAIRE

HEALTH HISTORY QUESTIONNAIRE
Answer each question by printing the necessary information. Your answers are confidential.

PERSONAL INFORMATION:
Name: _______________________________________ Date of Birth: _____________ Age:_______
Address : _____________________________________________________________________
City, State, Zip: ___________________________________________________________________
Home Phone: ________________________________ Work Phone:__________________________
Employer: ___________________________________Occupation: _______________________
In case of emergency, please notify:
Name: ______________________________________Relationship: ______________________
Address: ________________________________________________________________________
City, State, Zip: ___________________________________________________________________
Home Phone: ________________________________ Work Phone: ______________________

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: __________________________________________________________
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Are you taking any medications? Yes No (if yes, complete the following)
Type Dosage/Frequency Reason for taking:
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Please list any allergies: _____________________________________________________
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1. Has your doctor ever said your blood pressure was too high? Yes No
2. 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
3. Are you over age 65? Yes No
4. Are you unaccustomed to vigorous exercise? Yes No
5. Is there any reason not mentioned here why you should not follow a regular exercise program?Yes No
If so, please explain. ___________________________________________________
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6. Have you recently experienced any chest pain associated with either exercise or stress?Yes No
If so, please explain. ___________________________________________________
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Smoking
Please check the box that best describes your current habits:
Non-user or 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 a family history for any condition, please check the box to the left. If you are
personally experiencing any of these conditions, fill the information in on the line.
Asthma: ___________________________________________________________
Respiratory/Pulmonary Conditions: _____________________________________
Diabetes: Type I: _______ Type II: ________ How long? ____________________
Epilepsy: Petite Mal: ________ Grand Mal: _________ Other: ________________
Cardiovascular:
High Blood Pressure: ______________________________________________
High Cholesteol: _________________________________________________
Hyperlipidemia: __________________________________________________
Heart Disease: ___________________________________________________
Heart Attack: ____________________________________________________
Angina: _________________________________________________________
Stroke: _________________________________________________________
Gout: __________________________________________________________
Hypertension: ____________________________________________________
Family History of Cardiovascular (CV) Disease:
Please check the box that best describes your personal family history (blood relatives only):
No known history of heart disease
One relative over age 60 with CV disease
Two relatives over age 60 with CV disease
One relative under age 60 with CV disease
Two relatives under age 60 with CV disease
Three relatives under age 60 with CV disease
Gastrointestinal and Other:
High Blood Pressure: ______________________________________________
High Cholesteol: _________________________________________________
Hyperlipidemia: __________________________________________________
Heart Disease: ___________________________________________________
Heart Attack: ____________________________________________________
Arthritis/Bone Conditions: ___________________________________________
Cancer/Type: ____________________________________________________

MUSCULOSKELETALINFORMATION:
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: ___________________________________________________________
Upper Back: ___________________________________________________________
Shoulder / Clavicle: _____________________________________________________
Arm / Elbow: __________________________________________________________
Wrist / Hand: __________________________________________________________
Lower Back: ___________________________________________________________
Hip / Pelvis: ___________________________________________________________
Thigh / Knee: __________________________________________________________
Lower Leg / Ankle / Foot: ________________________________________________

NUTRITIONAL INFORMATION:
Are you on any specific food / nutritional plan at this time? Yes No
If yes, please list: _______________________________________________________
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Do you take dietary supplements? Yes No
If yes, please list: _______________________________________________________
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Do you experience any frequent weight fluctuations? Yes No
Have you experienced a recent weight gain or loss? Yes No
If yes, list change: ______________________________________________________
Over how long? ________________________________________________________
How many beverages do you consume per day that contain caffeine? ______________
How would you describe your current nutritional habits? ________________________
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Other food/nutrition issues you want to include (eating habits, mealtimes, etc.)?
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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 work and intense recreational exertion
Sedentary work and moderate recreational exertion
Sedentary work and light recreational exertion
Complete lack of all exertion
To what degree do you perceive your environment as stressful?
Work Minimal Moderate Average Extremely
Home Minimal Moderate Average Extremely
Do you work more than 40 hours a week? __________________
Please make any other comments you feel are pertinent to your exercise program.
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Screening Questionnaire

Has a doctor ever said you have heart trouble? Yes No
Have you ever had angina pectoris, sharp pain, or heavy
pressure in your chest as a result of exercise, walking, or other
physical activity such as climbing stairs (Note: this does not
include the normal out of breath feeling that results from normal
activity.)? Yes No
Do you experience any sharp pain or extreme tightness in your
chest when you are hit with a cold blast of air? Yes No
Have you ever experienced rapid heart action of palpitations? Yes No
Have you ever had a real or suspected heart attack, coronary
occlusion, myocardial infarction, coronary insufficiency, or
thrombosis? Yes No
Have you ever had rheumatic fever? Yes No
Do you have diabetes, hypertension or high blood pressure? Yes No
Does anyone in your family have diabetes, hypertension or high
blood pressure? Yes No
Has more than one blood relative (parent, sibling, first cousin)
had a heart attack or coronary artery disease before the age of
60? Yes No
Have you ever taken any medication to lower your blood
pressure? Yes No
Have you ever taken medications or been on a special diet to
lower your cholesterol? Yes No
Have you ever taken digitalis, quinine, or any other drug for
your heart? Yes No
Have you ever taken nitroglycerine or any other tablets for chest pain - tablets you take by placing under the tongue? Yes No
Are you overweight? Yes No
Are you under a lot of stress? Yes No
Do you drink excessively? Yes No
Do you have a physical condition, impairment or disability,
including a joint or muscle problem, that should be considered
before you undertake an exercise program? Yes No
Do you exercise fewer than three times per week? Yes No
Has a doctor told you not to participate in any kind of exercise program?
Do you have any limitations I need to know about when planning your exercise programs?

Exercise History Questionnaire
Are you currently involved in a regular exercise program? Yes No
Do you regularly walk or run 1 or more miles continuously? Yes No
If yes, what is the average number of miles you cover in a workout? ________
What is your average time per mile? _________________
Do you practice weightlifting or calisthenics? Yes No
Are you involved in an aerobic program? Yes No
If yes, what type(s)? ______________________________________________
Do you frequently compete in competitive sports? Yes No
If yes, which one(s)?
Golf Volleyball Bowling Football Tennis Baseball Handball Track Soccer
Other: ______________________
Basketball Average number of times per week: _______
In which of the following high school or college athletics did you participate?
None Track Football Swimming Basketball Tennis
Baseball Wrestling Soccer Golf Other: _______________
What activities would you prefer in a regular exercise program for yourself?
Walking and/or running Bicycling(outdoors) Swimming Stationary running
Stationary biking Tennis Jumping rope Handball Basketball Squash
Other: _____________________
Comments: ________________________________________________________
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Signed: ___________________________________ Date: ________
Witness: __________________________________ Date: ________