HEALTH HISTORY FORM

DATE

FITNESS HOUSECALLS

NAME: (required)

AGE: (required)

SEX: (required)

PHONE NUMBER 1: (required)

PHONE NUMBER 2:

PHONE NUMBER 3:

PHYSICIAN: (required)

PHONE: (required)

EMERGENCY CONTACT PERSON:

PHONE:

MEDICATIONS:

List physical activities you participate in regularly.

Has a doctor ever said your blood pressure was too high?

Has a doctor ever said you have heart trouble?

Has a doctor ever advised you not to exercise?

Do you frequently have pains in your chest?

Do you frequently feel faint or have dizzy spells?

Do you have difficulty with physical exercise?

Do you have a chronic illness?

LIST:

Do you have a history of lung or respiratory problems?

Do you have diabetes?

10.

Do you smoke?

If yes, how many packs a day?

11.

Do you have high blood cholesterol?

12.

Are you more than 30 lbs overweight?

13.

Have you had a surgery within the past 3 months?

LIST:

14.

Do you have any orthopedic problems that may be
aggravated with physical Activity?

If yes, explain:

15.

Are you pregnant?