Health Fair Toolkit Page 28
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35Confidential Record:
Information contained here will not be released without your authorization.
Have you ever had your cholesterol
measured?
NO
YES
Value:
Date:
Where:
Are you taking any Prescription or Non-Prescription medications?
Yes
No
(Please list below, include birth control pills)
Medication & Dose
Reason for Taking
For How Long?
Do you have any allergies to Medication?
YES
NO
(Include type of reaction)
Medication
Type of Reaction
Do you currently smoke?
NO
YES
If yes, what?
Cigarettes
Cigars
Pipe
How much per day?
<½ pack
½ - 1 pack
1 ½ to 2 packs
> 2 packs
Have you ever quit smoking?
NO
YES
When?
How many years and how much did you smoke?
Do you drink any alcoholic beverages?
NO
YES
If Yes, how much in 1 week?
Beer
(cans)
Wine
(glasses)
Hard liquor
(drinks)
Do you drink any caffeinated beverages?
NO
YES
If Yes, how much in 1 week?
Coffee
(cups)
Tea
(glasses)
Soft Drinks
(cans)
ACTIVITY LEVEL EVALUATION
Do you exercise regularly?
YES
NO
If so, what type?
How many days per week?
How much time per day? (check one)
< 15 min
15-30 min
30-45 min
>60 min
Do you ever have an uncomfortable shortness of breath during exercise?
YES
NO
Do you ever have chest discomfort during exercise?
YES
NO
If so, does it go away with rest?
Physical Exam: Vital Signs
Height
Weight
Temperature
Blood Pressure
Pulse
Any additional concerns you’d like to share today?
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