• HEALTH HISTORY QUESTIONNAIRE

    HEALTH HISTORY QUESTIONNAIRE

  • Format: (000) 000-0000.

  • Confidentiality Notice


    Your responses help tailor your coaching experience and mindbody performance plan. They are kept confidential and are not used for diagnosis or treatment. Life coaching is not psychotherapy and does not replace medical or mental-health care. If you have concerns about your mental or emotional health, please consult a qualified mental-health professional. By completing this section, you acknowledge personal responsibility for your own well-being during this program.

  • Please answer the following questions to the best of your ability. For the following questions, unless otherwise indicated, choose the single best choice for each question. All of your responses are completely confidential and may only be used in group summaries and/or reports. All information collected is subject to the Privacy Act of 1974. If you have any physical handicaps or limitations that would require special assistance with this questionnaire, please let your certified coach know. This form is in accordance with the American College of Sports Medicine guidelines for risk stratification when followed correctly by a certified professional.

  • Mental Health History

  • How would you describe your overall emotional state in the past month?
  • Do you currently experience persistent feelings of anxiety, sadness, or irritability?
  • Have you ever been diagnosed with depression, anxiety, PTSD, bipolar disorder, or another mental-health condition?
  • Are you currently seeing a therapist, counselor, psychiatrist, or other mental-health provider?
  • Are you currently taking any prescription or over-the-counter medications that affect mood, energy, or sleep (e.g., antidepressants, anti-anxiety, ADHD, or sleep medications)?
  • Do you use alcohol, nicotine, cannabis, or other substances more than occasionally?
  • Quality:
  • Do you experience frequent fatigue, brain fog, or burnout symptoms?
  • Do you have a supportive network of friends or family?
  • In the past year, have you experienced any significant losses, traumas, or major life changes?
  • Are you currently experiencing any thoughts of self-harm or suicide?

  • If “Yes,” please stop and reach out now to a licensed professional or call 988 (the Suicide & Crisis Lifeline in the U.S.).

  • Physical Health History

  • 1. Have you ever had a definite or suspected heart attack or stroke?
  • 2. Have you ever had coronary bypass surgery or any other type of heart surgery?
  • 3. Have you ever had coronary bypass surgery or any other type of heart surgery?
  • 4. Do you have any other cardiovascular or pulmonary (lung) disease(other than asthma. allergies. or mitral valve prolapse)?
  • 5. Do you have a history of: diabetes, thyroid, kidney, liver disease? (select/circle all that apply)tion
  • 6. Have you ever been told by a health professional that you have had an abnormal resting or exercise treadmill electrocardiogram (EKG)?

  • 8. Do you currently have any of the following:

  • a. pain or discomfort in the chest or surrounding areas that occurs when you engage in physical activity?
  • b. shortness of breath
  • c. unexplained dizziness or fainting
  • d. difficulty breathing at night except in upright position
  • e. swelling of the ankles (recurrent and unrelated to injury)
  • f. heart palpitations (irregularity or racing of the heart on more than one occasion)
  • g. pain in the legs that causes you to stop walking (claudication)
  • 9. Are you pregnant or is it likely that you could be pregnant at this time?
  • 10. Have you had surgery or been diagnosed with any disease in the past 3 months?
  • 11. Have you had high blood cholesterol or abnormal lipids within the past 12 months or are you taking medication to control your lipids?
  • 12. Do you currently smoke cigarettes or have quit within the past 6 months?
  • 13. Have your father or brother(s) had heart disease prior to age 55 OR mother or sister(s) had heart disease prior to age 65?
  • 14. Within the past 12 months, has a health professional told you that you have high blood pressure (systolic > 140 OR diastolic > 90)?
  • 15. Currently, do you have high blood pressure or within the past 12 months, have you taken any medicines to control your blood pressure?
  • 16. Have you ever been told by a health professional that you have a fasting blood glucose greater than or equal to 110 mg/dl?

  • 17. Describe your regular physical activity or exercise program:

  • 19. Are you currently under any treatment for any blood clots?
  • 20. Do you have any problems with bones, joints, or muscles that may be aggravated with exercise?
  • 21. Do you have any back/neck problems?
  • 22. Have you been told by a health professional that you should not exercise?
  • 23. Are you currently being treated for any other medical condition by a physician?
  • 24. Are there any other conditions (mitral valve prolapse, epilepsy, history of rheumatic fever, asthma, cancer, anemia, hepatitis, etc. that may hinder your ability to exercise?
  • 25. During the past six months, have you experienced any unexplained weight loss or gain (greater than ten pounds for no know reason)?

  • 27. Please list below all prescription and over-the-counter medications you are currently taking:

     

  • 28. Are there any medicines that your physician has prescribed to you in the past 12 months which you are currently not taking?

  • I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in the development of my fitness/wellness program and that it is my responsibility to contact a qualified professional about the suitability of fitness training and life coaching for my needs. If any of the above conditions change, I will immediately inform my Coach/Trainer of those changes. I understand that information regarding my medical or physical conditions is being collected for information purposes only. I knowingly and willingly assume all risks of injury resulting from training/coaching by Deborah Denova. Additionally, I knowingly and willingly assume all risks of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the attached questionnaire.

  • If “Yes,” please stop and reach out now to a licensed professional or call 988 (the Suicide & Crisis Lifeline in the U.S.).

  • Should be Empty: