Health History Questionnaire

Health History Questionnaire
Participant's Name

First NameLast Name
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Please state if you have current/previous health diseases/issues.
Please state whether you take any medication.
Do you currently have, are being treated for or have had any of the following: (CHECK ALL THAT APPLY)

DiabetesCancerOsteoporosisHypertensionElevated CholesterolArthritisHeart DiseaseThyroid IssuesAsthmaOther
Are you currently under physician's care for any medical condition(s) not listed above? If yes, please list the condition(s) below.
Are you currently taking any medications? If yes, please list below.
Do you have back, neck, or any other orthopedic concerns? If yes, please list below.
Have you ever had a stroke, heart attack, heart surgery, or any other cardiac instances? If yes, please explain below.
Are you a smoker? Y / N If yes, how much/often?
Do you currently participate in regular physical activity? Please list type and frequency of activity below.
I hereby acknowledge that the information I've given above is complete and accurate. I am informed that my information in this form will be kept confidential. I release and discharge Campbell Performance, LLC, and its representatives from any disclosure of my personal information in this Health History Questionnaire Form. If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the Campbell Performance, LLC representatives immediately.
Date

MonthDayYear
Date
Participant's Signature (Or legal guardian if under 18)

Clear
Should be Empty: