Medical History Form
Date
-
Month
-
Day
Year
Member Number
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Height
example@example.com
Weight (lbs)
Referred By
Referring physician
Primary Care Physician
Name
Telephone
Emergency Contact
Name
Telephone
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
Please provide additional details as needed.
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Please provide additional details as needed.
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
How often do you currently exercise?
Daily
Weekly
Monthly
Occasionally
Never
What are your current types of exercise, if so?
Basketball
Cycling
Pickleball
Pilates
Running
Swimming
Tennis
Walking
Weights
Yoga
Other
What are your preferred days to exercise?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What are your preferred times to exercise?
Early morning
Mid-morning
Noon
Afternoon
Early evening
Evening
What are your primary fitness goals?
Improve cardiovascular fitness
Increase strength and endurance
Improve body composition
Improve functional mobility
Please provide additional details as needed.
I acknowledge that I have read this document in its entirety or that it has been read to me (if I have been unable to read the same) and that I understand its meaning. I consent to the rendition of all services and the procedures as explained herein by an or all program personnel. I have had the opportunity to make all inquiries I deemed appropriate, and all such inquiries have been addressed to my satisfaction. Furthermore, I confirm that I have filled out this form in its entirety and have answered every question to the full extent of my knowledge.
Member Signature
Parent/Guardian Signature (if under 18)
Continue
Continue
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