Health History

 

Date     

Name

     
Date of Birth     
Sex      Male  Female
Height      Feet  Inches
Weight      lbs
Address     
City     
State     
Zip Code     
Country     
Email Address     
Home Phone     
Work Phone     
Occupation     
Physician     
Physician Phone     
   

 

Are you under the care of a physician or other health care professional? yes  no
If yes, please list reason.
 
  
Are you taking any medications? yes  no
If yes, please list type, dosage, and reason.
 
  
Do you smoke or use any tobacco products now or have you ever? yes  no
If yes, please list how much and if/when you quit.
 
  
Do you have any allergies? yes  no
If yes, please list.
  
Has your doctor ever said your blood pressure was too high? yes  no
Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise? yes  no
Are you over age 65? yes  no
Are you unaccustomed to vigorous exercise? yes  no
Is there any reason not mentioned here why you should not follow a regular exercise program? yes  no
If yes, please explain.
  
Have you recently experienced any chest pain associated with either exercise or stress? yes  no
If yes, please explain.
  
Do you now or have you had in the past any of the following?
Asthma
Respiratory/Pulmonary conditions
Diabetes
Epilepsy
Gastrointestinal Disorder
Thyroid Disorder
Hypoglycemia
High Blood Pressure
High Cholesterol
Heart Disease
Gout
Angina
  
Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort:
  
Please describe your current exercise habits and routines.
  
   
Has a doctor ever said you have heart trouble? yes  no

Have you ever had angina pectoris, sharp pain, or heavy pressure in your chest as a result of exercise, walking, or other physical activity such as climbing stairs (Note: this does not include the normal out of breath feeling that results from normal activity.)?

 yes  no

Do you experience any sharp pain or extreme tightness in your chest when you are hit with a cold blast of air?

 yes  no
Have you ever experienced rapid heart action or palpitations? yes  no

Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction, coronary insufficiency, or thrombosis?

 yes  no
Have you ever had rheumatic fever? yes  no
Do you have diabetes, hypertension or high blood pressure? yes  no

Does anyone in your family have diabetes, hypertension or high blood pressure?

 yes  no

Has more than one blood relative (parent, sibling, first cousin) had a heart attack or coronary artery disease before the age of 60?

 yes  no

Have you ever taken any medication to lower your blood pressure?

 yes  no

Have you ever taken medications or been on a special diet to lower your cholesterol?

 yes  no

Have you ever taken digitalis, quinine, or any other drug for your heart?

 yes  no

Have you ever taken nitroglycerine or any other tablets for chest pain - tablets you take by placing under the tongue?

 yes  no
Are you overweight? yes  no
Are you under a lot of stress? yes  no
Do you drink excessively? yes  no
Do you smoke cigarettes? yes  no

Do you have a physical condition, impairment or disability, including a joint or muscle problem, that should be considered before you undertake an exercise program?

 yes  no
Are you more than 65 years old? yes  no
Are you more that 35 years old? yes  no
Do you exercise fewer than three times per week? yes  no
Are you pregnant now or in the past 3 months? yes  no
   
What are your primary fitness goal?
  
What equipment do you have available to you?
  

By clicking the "Submit" button, I am confirming that I have read the disclaimers at the bottom of the Documents page.  I also give my consent to participate in the training program conducted by TOPFIT Personal Training.

I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the cardiorespiratory system (dizziness, discomfort in breathing, heart attack). I hereby certify that I know of no medical problem (except those noted on this form) that would increase my risk of illness and injury as a result of participation in a regular exercise program.