Health And Fitness Assessment Questionnaire (Vitality)
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4Health and Fitness Assessment
Questionnaire (Vitality)
SECTION 1. DEMOGRAPHICS
1.1
Details: Please print in capital letters using black ink and tick the relevant box(es).
-
M
F
Age
Gender
Male - Female
First name
Surname
/
/
Y Y
Y
Y
Birth Date
D D
M M
ID Number
Title
Medical aid membership number
Medical Aid
(
) -
-
(
) -
-
Work number
Home number
(
) -
-
(
) -
-
Cell phone number
Fax number
@
Email
SECTION 2. MEDICAL HISTORY
2.1
Family History: Do you have a family history (parents or siblings) of any of the following medical conditions?
Yes
Before or at the age of 50
High Cholesterol
Yes
Before or at the age of 50
Heart Disease
Yes
Before or at the age of 50
Yes
Before or at the age of 50
High Blood Pressure
Insulin Dependant Diabetes
Stroke
Non Insulin Dependant Diabetes
Yes
Before or at the age of 50
Yes
Before or at the age of 50
Peripheral Vascular Disease
Cancer
Yes
Before or at the age of 50
Yes
Before or at the age of 50
Type:
2.2.
Personal Medical History: Have you suffered, or do you suffer from any of these medical conditions?
High Cholesterol
Yes
Heart Disease
Yes
Exercise Induced Asthma
Yes
ancer
Insulin Dependant Diabetes
Non Insulin Dependant Diabetes
Asthma
Yes
Yes
Yes
Peripheral Vascular Disease
Stroke
High Blood Pressure
Yes
Yes
Yes
Cancer
Yes
Type:
Diagnosed by?
cardiologist
specialist physician
medical practitioner
blood test
Diagnosed when?
in the past year
1 - 5 years ago
> 5 years ago
Specific Intervention?
healthy dietary
medication
regular activity
habits
2.3.
Medication
Are you currently on medication for heart disease, peripheral vascular disease, cholesterol and/or blood pressure?
Yes
No
If yes, please write your medical condition, name of medication and dosages, below:
Condition: eg. Cholesterol
Medication: eg. Lipitor
/
Dosage: eg.10mg 1
day
2.4.
Preclusions
Present Symptoms: Do you suffer from any of these medical conditions?
Chest pains while exercising
Yes
No
Frequent fainting and/or dizzy spells
Yes
No
Any flu-like symptoms (fever and/or muscle pains)
Yes
No
Palpitations
Yes
No
Frequent wheezing /coughing
Yes
No
Shortness of breath at rest or with activity
Yes
No
Ankle edema
Yes
No
Intermittent claudication
Yes
No
Known heart murmur
Unusual fatigue with usual activities
Yes
No
Yes
No
Physical Injury: Do you currently suffer from any physical ailment that would preclude you from performing this assessment?
Neuromuscular Disease
Yes
No
Yes
No
Ligament
Bone
Yes
No
Muscle
Yes
No
Joint
Yes
No
Other
Yes
No
Assessor's comment (
)
based on ACSM's risk factors for exercise testing
Yes
No
In your professional opinion, is the member fit to continue with this assessment?
COMMENT:
2.5.
Pregnancy
Are you currently pregnant?
Yes
No
If yes, how many months pregnant are you? (e.g. 5)
months
Do you have clearance from your gynaecologist to perform this assessment?
Yes
No
VLC_Vit_H&FA_questionnaire_26102011pdf
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