Health Screening Form - Dcrc
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1Health Screening Form
Name_________________________________________Date__________ Home Phone______________
Male_______Female_______ Age_______ Height_______ Weight________
This form is intended to obtain relevant information about your health that will assist staff in helping you
with your fitness assessment and/or exercise program. Please answer all questions to the best of your
knowledge.
1. Have you ever been diagnosed with hypertension (high blood pressure)?
YES
NO
2. Have you ever had a blood pressure reading higher than 160/90 on at least
two separate occasions?
YES
NO
3. Are you currently on antihypertensive (high blood pressure) medication?
YES
NO
4. Have you ever had a cholesterol reading above 240?
YES
NO
5. Do you currently smoke?
YES
NO
6. Do you have Diabetes Mellitus?
YES
NO
If yes, are you insulin dependent?___________How long?_________
7. Do you have any siblings or parents that have had heart attacks, heart disease
or other atherosclerotic disease prior to age 55?
YES
NO
8. Have you ever had chest pain, heart attack, heart disease or other
atherosclerotic disease?
YES
NO
9. Do you have any serious orthopedic problems that would prevent you from
exercising?
YES
NO
10. Do you have any reason to believe that you should not exercise?
YES
NO
11. Please list any medications that you are currently taking and any allergies that you might have:
____________________________________________________________________________________
12. Please list the person that you would like us to contact in the event of an emergency:
Name:__________________________________Phone:__________________________
Relation:___________________ Address:_____________________________________
Fax to: DCRC
Mail to: DCRC
For questions please contact:
ATTN: T.J. Putnam
ATTN: T.J. Putnam
T.J. Putnam
614-761-6545
5600 Post Road
Fitness & Wellness Coordinator
Dublin, Ohio 43017
614-410-4584
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