Medical History Form
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1
2Medical History Form
Name: __________________________________ Date: _______________________________
Telephone: ______________________________
Date of Birth:_______ Age: _________
Height: _____________
Weight:________
In Case of Emergency Contact: ____________________________ Relationship:___________
Address: ____________________________
Phone: _______
Physician: ____________________________
Specialty: _______
Address: _______
Phone: _______
Are you currently under a doctor’s care:
Yes
No
If yes, explain: ____________________________
When was the last time you had a physical examination? ____________________________
Have you ever had an exercise stress test:
Yes
No
Don’t Know
If yes, were the results:
Normal
Abnormal
Do you take any medications on a regular basis?
Yes
No
If yes, please list medications and reasons for taking: ____________________________
Have you been recently hospitalized?
Yes
No
If yes, explain: ____________________________
Do you smoke?
Yes
No
Are you pregnant?
Yes
No
Do you drink alcohol more than three times/week?
Yes
No
Is your stress level high?
Yes
No
Are you moderately active on most days of the week?
Yes
No
Do you have:
High blood pressure?
Yes
No
High cholesterol?
Yes
No
Diabetes?
Yes
No
Have parents or siblings who, prior to age 55 had:
Yes
No
A heart attack?
Yes
No
A stroke?
Yes
No
High blood pressure?
Yes
No
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Parent category: Medical