Health/medical Questionnaire Form
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1
2Health/Medical Questionnaire
Date: _________________________
Name: _____________________________ Date of birth: ______________
Soc. Sec. #: __________________
Address: _______________________________________________________________________________________
Street
City
State
Zip
Phone (H): ____________________ (W): ____________________ E-mail address: __________________________
In case of emergency, whom may we contact?
Name: ______________________________________ Relationship: _____________________________________
Phone (H): ________________________________________ (W): _______________________________________
Personal physician
Name: __________________________________ Phone: ____________________ Fax: ____________________
Present/Past History
Have you had OR do you presently have any of the following conditions? (Check if yes .)
___
Rheumatic fever
___
Recent operation
___
Edema (swelling of ankles)
___
High blood pressure
___
Injury to back or knees
___
Low blood pressure
___
Seizures
___
Lung disease
___
Heart attack
___
Fainting or dizziness with or without physical exertion
___
Diabetes
___
High cholesterol
___
Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack) nocturnal
dyspnea (shortness of breath at night)
___
Shortness of breath at rest or with mild exertion
___
Chest pains
___
Palpitations or tachycardia (unusually strong or rapid heartbeat)
___
Intermittent claudication (calf cramping)
___
Pain, discomfort in the chest, neck, jaw, arms, or other areas with or without physical exertion
___
Known heart murmur
___
Unusual fatigue or shortness of breath with usual activities
___
Temporary loss of visual acuity or speech, or short-term numbness or weakness in one side, arm, or leg of
your body
___
Other
Family History
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions?
(Check if yes .) In addition, please identify at what age the condition occurred.
___
Heart arrhythmia
___
Heart attack
___
Heart operation
___
Congenital heart disease
___
Premature death before age 50
___
Significant disability secondary to a heart condition
___
Marfan syndrome
___
High blood pressure
___
High cholesterol
___
Diabetes
___
Other major illness _________________________
From NSCA, 2012, NSCA’s essentials of personal training, 2nd ed., J. Coburn and M. Malek (eds.), (Champaign, IL: Human Kinetics).
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