Health History Questionnaire

Physician

First NameLast Name

Phone Number

Please enter a valid phone number.

Are you under the care of a physician, chiropractor, or other health care professional for any reason? Ifyes, list reason:

YesNo

Reason

Are you taking any medications?

YesNo

(If yes, complete the following)
Type:
Dosage/Frequency:   Type a label
Reason for Taking:   Type a label

Please list any allergies:

Has your doctor ever said your blood pressure was too high?

YesNo

Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?

YesNo

Are you accustomed to vigorous exercise? (sports?)

YesNo

Is there any reason not mentioned why you should not follow a regular exercise program?

YesNo

If yes, please explain:

If there is family history for any condition?

Please check the box that describes your current habits:
Non-user or former user; Date quit: More than 35 cigarettes per day Caffeine Intake/Daily: Alcohol Intake/Weekly:

Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort:

❒Head/Neck:   Type a label
❒ Upper Back:   Type a label
❒ Shoulder/Clavicle:   Type a label
❒ Arm/Elbow:   Type a label
❒ Wrist/Hand:   Type a label
❒ Lower Back:   Type a label
❒ Hip/Pelvis:   Type a label
❒ Thigh/Knee:   Type a label
❒ Arthritis:   Type a label
❒ Hernia:   Type a label
❒ Surgeries:   Type a label
❒ Other:   Type a label

Are you on any specific food/diet plan at this time?

YesNo

If yes, please list:

Do you take dietary supplements?

YesNo

If yes, please list:

Have you experienced a recent weight gain or loss?

YesNo

If yes, list change and over how long?

How would you describe your current nutritional habits?

Other food/nutritional issues you want to include (food allergies, mealtimes, etc.)

Please make any other comments you feel are pertinent to your exercise program.

Health History Questionnaire

In Case of Emergency, please notify:

MEDICAL INFORMATION

LIFESTYLE HABITS

MUSCULOSKELETAL INFORMATION

NUTRITIONAL INFORMATION