Adult Health History

Today's Date

Date

Name*

First NameLast Name

Gender*

MaleFemale

Birth date

Date

Age*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation

Home or Cell Phone*

Area CodePhone Number

Work Phone

Area CodePhone Number

Email*

example@example.com

In Case of Emergency, Please Notify:*

First NameLast Name

Emergency Contact Relationship*

Emergency Contact Phone*

Area CodePhone Number

Physician Name*

First NameLast Name

Physician Phone*

Area CodePhone Number

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

YesNo

If yes, list reason:

Are you taking any medications?*

YesNo

If yes, list type, dosage/frequency, reason for taking:

Please list any allergies:

High or low blood pressure?*

YesNo

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

YesNo

Are you over the age of 65?*

YesNo

Are you unaccustomed to vigorous exercise?*

YesNo

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

YesNo

Have you recently experienced any chest pain associated with either exercise or stress?*

YesNo

If yes, explain:

More info about respiratory problems

Respiratory/Pulmonary Conditions*

YesNo

If yes, explain:

More info about headaches or diziness

Diabetes?*

YesNo

If yes, explain:

More info about musculoskeletal problems

Epilepsy?*

YesNo

If yes, explain:

More info about recent surgeries

Osteoporosis?*

YesNo

If yes, explain:

More info about sustained injuries or illness

Occupational Stress Level*

MinimalModerateAverageExtreme

Do you work more than 40 hours per week?*

YesNo

Please check the box that best describes your work and exercise habits:

Intense occupational and recreational exertionModerate occupational and recreational exertionSedentary occupational and intense recreational exertionSedentary occupational and moderate recreational exertionSedentary occupational and light recreational exertionComplete lack of all exertion

Please make any other comments you feel are pertinent to your work environment.

Home Stress Level*

MinimalModerateAverageExtreme

Energy Level*

LowMediumHigh

Caffeine Intake Daily

Alcohol Intake Weekly

Colds per year

Hypoglycemia*

YesNo

Pre/Post-natal*

YesNo

Anemia*

YesNo

Thyroid Disorder*

YesNo

High blood pressure*

YesNo

Hypertension*

YesNo

High Cholesterol*

YesNo

Hyperlipidemia*

YesNo

Heart Disease*

YesNo

Heart Attack*

YesNo

Angina*

YesNo

Stroke*

YesNo

Gout*

YesNo

Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, strains, 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:

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

YesNo

If yes, please list:

Do you take dietarysupplements?*

YesNo

If yes, please list:

Do you experience any frequent weight fluctuations?*

YesNo

Have you experienced any recent weight gain or loss*

YesNo

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.)

Are you currently involved in a regular exercise program?*

YesNo

Do you regularly walk or run 1 or more miles continuously?*

YesNo

If yes, what is the average number of miles you cover in a workout?

What is your average time per mile?

Do you practice weightlifting or calisthenics?*

YesNo

Are you involved in an aerobic program?*

YesNo

Do you frequently compete in competitive sports? If yes, which ones?

Average number of times per week

Did you participate in high school or college athletics? If yes, which ones?

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.

If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15-69, the Par-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: Check YES or NO.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

YesNo

Do you feel pain in your chest when you do physical activity?*

YesNo

In the past month, have you had chest pain whe you are not doing physical activity?*

YesNo

Do you lose your balance because of dizziness or do you ever lose consciousness?*

YesNo

Do you have a bone or joint problem (for example, back, neck, knee, or hip) that could be made worse by a change in your physical activity?*

YesNo

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*

YesNo

Do you know any other reason why you should not do physical activity?*

YesNo

If you answered YES to more that ONE of these questions:

Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.

You may be able to do any activity you want as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

Find out which community programs are safe and helpful to you.

If you answered NO Honestly to all Par-Q questions, you can be reasonably sure that you can:

Start becoming much more physically active. Begin slowly and build up gradually. This is the safest and easiest way to go. You may also want to take part in a fitness appraisal. This is an excellent way to determine your basic fitness so that you can plan the best for you to live actively. It is also highlyrecommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.

DELAY BECOMING MUCH MORE ACTIVE:

If you are not feeling well because of a temporary illness such as a cold or a fever. Wait until you feel better. Or if you are or may be pregnant talk to your doctor before you start becoming more active.

PLEASE NOTE: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

Date

I acknowledge the above information to be true and accurate. To the best of my knowledge, I have given all relevant information regarding my health and ability to participate safely in an exercise program.*

Signature

Health History

Medical Information

Family Medical History

Lifestyle and Dietary Factors

Personal Medical History, continued

Nutritional Information

Exercise History

PAR-Q and YOU