HEALTH HISTORY FORM Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Personal Physician Name and Number * Personal Training Par-Q (Physical Activity Readiness Questionnaire) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? * YES NO Do you feel pain in your chest when you do physical activity? * YES NO Do you lose your balance because of dizziness or do you ever lose consciousness? * YES NO Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by change in your physical activity? * YES NO Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? * YES NO If you checked “yes” for any question #1-#6, the “National Strength and Conditioning Association” states that you must receive clearance from your physician prior to participating in a progressive resistance exercise program. I have read this entire document and have answered all of the questions to the best of my knowledge. * Medical History 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 or ankles) High blood pressure Injury to back or knees Low blood pressure Seizures Lung disease Heat attack Fainting or dizziness 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 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 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 attack Heat operation Congenital heart disease High blood pressure High cholesterol Diabetes Other major illness Explain checked items: Activity History How were your referred to this program? (Please be specific.) * Why are you enrolling in this program? (Please be specific.) * Are you presently employed? yes no What is your present occupational position and company name * Have you ever worked with a personal trainer before? * yes no 7. Date of you last physical examination preformed by a physician: * MM DD YYYY Do you participate in a regular exercise program at this time? * yes no Please explain activity, frequency and details about what you are doing: * Can you currently walk 4 miles briskly without fatigue? * yes no Have you ever performed resistance training exercises in the past? * yes no Do you have injuries (bone or muscle disabilities) that may interfere with exercising? * yes no If yes, briefly describe. Do you smoke? yes no If yes, how much per day and what was your age when you started? How high is the level of stress in your life? * high moderate low What is your body weight or size now? * What was it one year ago? * Do you consider yourself: * At my goal weight/body composition for maintenance At a weight lower than optimal for health and fitness At a weight higher than optimal for health and fitness Do you follow or have you recently followed any specific dietary intake plan, and in general how do you feel about your nutritional habits? * List the medications, nutritional supplements(s)/herbs, etc. you are presently taking. * Medication, supplement or herb Dosage Frequency List in order your personal health and fitness objectives. * Thank you! I’ll be in touch soon.
