Client Information & Health Questionnaire

This health history questionnaire will be used for identifying high-risk situations and avoiding any unnecessary risks.
Regular physical activity is safe for most people. However, some individuals should consult with their physician
before increasing physical activity.

The answers to the following questions will be used to better understand your health and fitness levels.
Some of the activities that you may engage in may be physically stressful and may present a risk to you.
All information will be kept confidential.

How active do you consider yourself?

Very

Somewhat

Poor

How would you rate your energy level?

Excellent

Good

Poor

Do you exercise regularly?

Yes

No

How often?

Carrdio

Yes

No

How often?

Weight Conditioning?

Yes

No

How often?

Do you smoke cigarettes?

Yes

No

Do you have Plantar’s warts on you hands or feet?

Yes

No

Has your doctor ever advised you to limit your physical activity?

Yes

No

If yes, please explain the circumstances

Have you had a heart attack?

Yes

No

If yes at what age did the attack occur?

Have you been diagnosed as having any heart abnormalities?

Yes

No

If yes, what heart condition(s) have been diagnosed and when

Have you had a stroke?

Yes

No

If yes at what age did the attack occur?

Have you been diagnosed as having a metabolic condition (liver, kidney, thyroid)?

Yes

No

If yes, please name the condition and state how long you have had the condition

Have you been diagnosed with diabetes?

Yes

No

If yes, what type of diabetes and how long have you had diabetes

Have you been diagnosed as having a autoimmune condition (MS, lupis)?

Yes

No

If yes, please name the condition and state how long you have had the condition

Have you been diagnosed with high blood pressure?

Yes

No

Have you been diagnosed with low blood pressure?

Yes

No

Do you ever experience shortness of breath?

Yes

No

Do you ever experience lightheadedness, dizziness, fainting?

Yes

No

Do you have any intestinal conditions (IBS, Crohns, Colitis)?

Yes

No

Do you ever experience difficulty breathing when standing or suddenly at night?

Yes

No

If yes, please name the condition and state how long you have had the condition

Do you ever experience a rapid heart beat or fluttering of the heart?

Yes

No

Do you have a heart murmur?

Yes

No

Do you experience severe leg pain when walking or stationary?

Yes

No

Has any member of your family had any of the following conditions (please list family members for all that apply)

Heart Attack (prior to age 55)

High Blood pressure

High Cholesterol

Metabolic Disease liver/kidney)

Osteoporosis

Stroke

Asthma

Leukemia

Obesity

Do you have edema (ankle swelling)?

Yes

No

Do you have any bone or joint problems (arthritis, bursitis)?

Yes

No

If yes, please detail condition and joints/bones affected

Have you had any injuries or do you experience pain in your neck, back or spine?

Yes

No

If yes please explain the pain and/or injury

Have you had any injuries to your knees?

Yes

No

If yes where and when did the injury occur

Have you had any torn/ruptured/sprained muscles or tendons?

Yes

No

If yes where and when did the injury occur

Have you had any broken bones?

Yes

No

If yes where and when did the injury occur

Have you had any other sports or fitness related injuries?

Yes

No

If yes where and when did the injury occur

Is there other information that might affect your ability to perform physical exercise?

Yes

No

If yes please explain the circumstances

Have you ever been hospitalized?

Yes

No

If yes please explain the circumstances

Do you have any children?

Yes

No

If yes did you have a Cesarean birth?

Yes

No

If yes how many and how old are they?

Are you pregnant?

Yes

No

If yes has your doctor given permission to perform physical exercise?

Yes

No

Are you taking any prescription medications?

Yes

No

If yes please list the medication and what it has been prescribed for

Are you taking any over the counter medications/supplements?

Yes

No

If yes please list the medication and its purpose

Are you taking any seizure medications?

Yes

No

Do any of the medications you take have the ability to affect your heart, lungs or consciousness while exercising?

Yes

No

Client Information & Health Questionnaire

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Client Information & Health Questionnaire

Emergency Contact Information

Health Information

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Categories

Latest Tweets

New Clients Must Complete

Schedule A Class

Refer A Friend

Sign up for our mailing list.

Contact Information