International Sports Sciences Association
This form is adapted from ISSA client assessment materials
Medical History Questionnaire
PLEASE FILL OUT ALL INFORMATION REQUESTED BELOW
Member's Name:
Date:
-
Month
-
Day
Year
Date
Please indicate in the space provided if you have a history of the following:
1. Heart attack
YES
NO
2. Bypass or cardiac surgery
YES
NO
3. Chest discomfort with exertion
YES
NO
4. High blood pressure
YES
NO
5. Rapid or runaway heartbeat
YES
NO
6. Skipped heartbeat
YES
NO
7. Rheumatic fever
YES
NO
8. Phlebitis or embolism
YES
NO
9. Shortness of breath w/ or wo/exercise
YES
NO
10. Fainting or light-headedness
YES
NO
11. Pulmonary disease or disorder
YES
NO
12. High blood fat (lipid) level
YES
NO
13. Stroke
YES
NO
14. Recent hospitalization for any cause
YES
NO
List specifics:
15. Orthopedic problems (including arthritis)
YES
NO
List specifics:
FOR ANY OF THE CONDITIONS CHECKED ABOVE, PLEASE LIST THE DIAGNOSIS AND EXAMINING PHYSICIAN:
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