Health Screening Form - Ava Dorfman Center printable pdf download

Health Screening Form - Ava Dorfman Center

Health Screening Form

Name:_____________________________________ Date:__________________

Address:__________________________________________________________

Gender:_______ DOB:________ Age:______ Phone Number:________________

Interested in joining the Wellness Center?_____ Class?______________________

1. Recent Medical Care

Physician:________________________ Phone:_______________________

Address:______________________________________________________

Are you under a physician’s care for other conditions?__________________

Name of specialist?____________________ Phone:___________________

Past Surgeries: Yes / No Date:_________ Surgery____________________

Date: _________ Surgery_____________________

Physical Therapy: Yes / No Date:________ Reason:___________________

2. Blood Pressure

High Blood Pressure: Yes / No

Have you had High Blood Pressure in the past: Yes / No

Medication taken: Yes / No Name of medication: ____________________

3. Cholesterol

High Cholesterol: Yes / No Name of medication:_____________________

4. Heart Problems

Have you had a heart attack?

Yes / No

Have you ever had heart surgery?

Yes / No

Have you ever had angina?

Yes / No

Irregular heart beat?

Yes / No

Pacemaker?

Yes / No

Health Screening Form - Ava Dorfman Center