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Medical History Form
Gather more information about your patient to track their medical history.
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1
Full Name
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First Name
Last Name
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2
What is your Gender?
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Male
Female
Trans
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3
Check the conditions that apply to you:
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Any personal history of diabetes or other metabolic disease (thyroid,renal,liver)?
Any personal history of pulmonary disease, asthma, interstitial lung disease or cystic fibrosis?
Have you experienced pain or discomfort in your chest apparently due to blood flow deficiency?
Any unaccustomed shortness of breath (perhaps during light exercise)?
Have you had any problems with dizziness or fainting?
Do you have difficulty breathing while standing or sudden breathing problems at night?
Do you have any personal history of heart disease (coronary or atherosclerotic disease)?
Have you experienced a rapid throbbing or fluttering of the heart?
Do you suffer from ankle edema (swelling of the ankles)?
Have you experienced severe pain in leg muscles during walking?
Do you have a known heart murmur?
Do you have high cholesterol?
Are you a cigarette smoker?
Would you characterize your lifestyle as "sedentary"?
Have you ever been told your BMI was greater than 30?
Do you have high blood pressure? (systolic > 140mmHg or diastolic > 90mmHg)
Do you have any family history of cardiac or pulmonary disease prior to age 55?
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4
Check the following that apply to you:
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Are you currently being treated for high blood pressure?
Abnormal EKG?
Asthma?
Bronchitis?
Emphysema?
Limited Range of Motion?
Arthritis?
Swollen or Painful Joints?
Knee Problems?
Foot Problems?
Recently Broken Bones?
Weight loss
Stroke?
Do You Suffer fromEpilepsy or Seizures?
Persistent Fatigue?
Hernia?
Anemia?
Are You Pregnant?
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5
Have your mother, father, or siblings suffered from (please select all that apply):
Heart attack or surgery prior to age 55.
High cholesterol
Stroke prior to age 50.
Diabetes
Congenital heart disease or left ventricular
hypertrophy.
Obesity
Hypertension
Asthma
Leukemia or cancer prior to age 60. Osteoporosis
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6
Please select any medications you are currently using:
Diuretics
Other Cardiovascular
Beta Blockers
NSAIDS/Anti-inflammatories (Motrin, Advil)
Vasodilators
Cholesterol
Alpha Blockers
Diabetes/Insulin
Calcium Channel Blockers
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7
Do you have any medication allergies?
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Yes
No
Not Sure
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8
Please list any drug specifics that you currently take:
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9
Please select your daily stress levels:
Low
Moderate
High but manageable
High: sometimes difficult to handle
Very High: Difficult to handle
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10
Please select all that apply to your dietary habits:
I eat high fat foods
I try to eat a low fat diet
I include fiber into my daily diet
I get 4 or more servings of fruit and veggies a day
I eat really sugary foods
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11
Do you use or do you have history of using tobacco?
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Please Select
Yes
No
No
Please Select
Yes
No
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12
How often do you consume alcohol?
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Daily
Weekly
Monthly
Occasionally
Never
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13
Please indicate any other medical conditions or activity restrictions that you may have, or any other information you feelis critical to understanding your readiness for exercise.
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