International Sports Sciences Association
This form is adapted from ISSA client assessment materials
Health History Questionnaire
ANSWER EACH QUESTION BY PRINTING THE NECESSARY INFORMATION. YOUR ANSWERS ARE CONFIDENTIAL.
Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Employer:
Occupation:
In case of emergency, please notify:
Name:
First Name
Last Name
Relationship:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
MEDICAL INFORMATION
Physician:
Phone:
Format: (000) 000-0000.
Are you under the care of a physician, chiropractor, or other health care professional for any reason?
Yes
No
If yes, list reason:
Are you taking any medications?
Yes
No
Type
Dosage/Frequency
Reason for Taking
Please list any allergies:
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 the age of 65?
Yes
No
Are you unaccustomed to vigorous exercise?
Yes
No
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International Sports Sciences Association
MEDICAL INFORMATION, CONTINUED
Is there any reason not mentioned 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:
SMOKING
Please check the box that describes your current habits:
Non-user or former user; Date quit:
Cigar and/or pipe
15 or less cigarettes per day
16 to 25 cigarettes per day
26 to 35 cigarettes per day
More than 35 cigarettes per day
FAMILY AND PERSONAL MEDICAL HISTORY
If there is family history for any condition, please check the box to the left. If you are personally experiencing any of these conditions, fill the information in on the line to the right.
Asthma:
Respiratory/Pulmonary Conditions:
Diabetes: Type I:
Type II:
How Long?
Epilepsy: Petite Mal:
Grand Mal:
Other:
Osteoporosis:
LIFESTYLE AND DIETARY FACTORS
Please fill in the information below:
Occupational Stress Level:
Low
Medium
High
Energy Level:
Low
Medium
High
Caffeine Intake/Daily:
Alcohol Intake/Weekly:
Colds Per Year:
Anemia:
Gastrointestinal Disorder:
Hypoglycemia:
Thyroid Disorder:
Pre/Postnatal:
CARDIOVASCULAR
Please fill in the information below:
High Blood Pressure:
Hypertension:
High Cholesterol:
Hyperlipidemia:
Heart Disease:
Heart Disease:
Heart Attack:
Stroke:
Angina:
Gout:
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International Sports Sciences Association
FAMILY AND PERSONAL MEDICAL HISTORY, CONTINUED
Health History Questionnaire
MUSCULOSKELETAL INFORMATION
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:
Upper Back:
Shoulder/Clavicle:
Arm/Elbow:
Wrist/Hand:
Lower Back:
Hip/Pelvis:
Thigh/Knee:
Arthritis:
Hernia:
Surgeries:
Other:
NUTRITIONAL INFORMATION
Are you on any specific food/diet plan at this time?
Yes
No
If yes, please list:
Do you take dietary supplements?
Yes
No
If yes, please list:
Do you experience any frequent weight fluctuations?
Yes
No
Have you experienced a recent weight gain or loss?
Yes
No
If yes, list change:
Over how long?
How many beverages do you consume per day that contain caffeine?
How would you describe your current nutritional habits?
Other food/nutritional issues you want to include (food allergies, mealtimes, etc.)
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International Sports Sciences Association
Health History Questionnaire
WORK AND EXERCISE HABITS
Please check the box that best describes your work and exercise Habits.
Intense occupational and recreational exertion
Moderate occupational and recreational exertion
Sedentary occupational and intense recreational exertion
Sedentary occupational and moderate recreational exertion
Sedentary occupational and light recreational exertion
Complete lack of all exertion
To what degree do you perceive your environment as stressful?
Minimal
Moderate
Average
Extremely
Minimal
Moderate
Average
Extremely
Do you work more than 40 hours a week?
Yes
No
Please make any other comments you feel are pertinent to your exercise program.
NAME:
SIGNATURE:
DATE:
SIGNATURE OF PARENT: or GUARDIAN (for participants under the age of majority)
WITNESS:
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