HEALTH HISTORY QUESTIONNAIRE
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- Rudolf Casey
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1 1 HEALTH HISTORY QUESTIONNAIRE Name: : Address: City: Phone: (Home) (Work) (Cell) of Birth: Emergency Contact: (Name) (Phone) Occupation: Relationship Status: Children: (# & ages) Height: Current Weight: One Year Ago: Five Years Ago: Fitness Goals: Body Weight & Goals Goal Weight: Two Years Ago: Ten Years Ago: Nutrition Goals: Health & Other Goals: How Can I help You Reach These Goals?
2 2 Describe your current level of activity: HEALTH HISTORY: PHYSICAL ACTIVITY Describe any physical activities you have been involved in the last 10 years and their results: What physical activities do you enjoy? What physical activities did you enjoy as a child? What physical activities do you dislike? What physical activities would you like to try? What kind of fitness equipment do you own? Do you currently belong to a health club or gym? What part of the day is your preference for physical activity? HEALTH HISTORY: NUTRITION What are your three favorite foods? What are your three least favorite foods? How often do you eat fast food?
3 3 HEALTH HISTORY: MEDICAL INFORMATION For most people, physical activity should not pose any problem or hazard. The following questions are designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering these questions. Please read them carefully and check the Yes or No response opposite the question if it applies to you. Yes No 1. Has your doctor ever said you have heart trouble? If yes, please describe the problem and state when it was diagnosed. 2. Do you frequently have pain in your heart or chest? 3. Do you often feel faint or have spells of severe dizziness? 4. Has a doctor ever told you that your blood pressure was too high? 5. Has your doctor ever told you that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse by exercise? 6. Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to do so? 7. Are you over age 65 and/or not accustomed to vigorous exercise? 8. Are you or have you ever been a diabetic? 9. Are you now pregnant, or have you been pregnant within the last 3 months? 10. Have you had any surgery in the last 3 months? 11. Have you been hospitalized in the last 2 years? If so, when and why? 12. Have you ever seen a chiropractor, acupuncturist, or other alternative medicine practitioner? If so, when and why? Please check the box if you have ever experienced any of the following symptoms: When first experienced Treatment used Pain or discomfort in the chest Unaccustomed shortness of breath Dizziness Labored or uncomfortable breathing, with or without pain Swollen ankles
4 4 Heart palpitations Heart murmur Limping Do you have high blood pressure? If yes, what is your current blood pressure without medication? Are you taking any medication for hypertension? If so, what medication? Is your total serum cholesterol level over 240? Do you smoke? Have you ever smoked? If so, when did you quit? Do you have diabetes? Do you have a family member who has had coronary or atherosclerotic disease before age 55? Do you have pain or discomfort in your back? Do you have pain or discomfort in your knee? If so, right or left? Do you have pain or discomfort in your shoulder? If so, right or left? Do you have pain or discomfort in your elbow? If so, right or left? Do you have pain or discomfort in your wrist? If so, right or left? Do you have pain or discomfort in your ankle? If so, right or left? If you checked Yes above, please describe your pain. On a scale of 1 to 10, with 1 being almost nonexistent and 10 being excruciating, how severe is it? Does it get more or less severe as the day goes on? When do you notice it? What really aggravates it?
5 5 Have you ever torn ligaments or cartilage in your knee? If so, when? Did you have surgery on this knee? If so, when? Have you ever dislocated your shoulder? If so, when? Have you ever had shoulder surgery? If so, which shoulder? When? Have you ever had a neck injury, such as whiplash? If so, when? Have you ever been treated for a spinal disk injury? If so, when? Do you ever experience tingling or numbness in your elbows or hands? What is the present state of your general health? HEALTH HISTORY: PERSONAL What regular physical activities do you do now? How often? For how long each session? _ What part of the day do you prefer to be active? What types of music do you enjoy? Is there any type of music you do NOT like at all? Do you prefer individual and small groups or large groups when exercising? Do you like indoor exercise or outdoor exercise? Does temperature bother you when exercising? If so, what type?
6 6 HEALTH HISTORY: SIGNATURE PAGE I,, certify that I understand the foregoing questions and my answers are true and complete. I also understand that this information is being provided as part of my initial consultation and may not be periodically updated. I,, assume the risk for any changes in my medical condition that might affect my ability to exercise. Signature Parent/Guardian Signature (if applicable) If you answered yes to one or more questions and you have not recently consulted with your doctor, do so before beginning an exercise program. Tell your doctor which questions you answered yes to and explain that you plan to undergo an exercise program that may include, but may not be limited to, weight and/or resistance training. After medical evaluation, ask your doctor 1. which activities you may safely participate in, and 2. what specific restrictions, if any, should apply to your condition and which activities and/or exercises you should avoid. I,, acknowledge that I have read the foregoing statements and understand the content thereof. Client Signature Parent/Guardian Signature (if applicable) Thank you for taking the time to fill out this form! I coach and train people holistically for Wellness. Wellness is High- Performance Health. Wellness is a lifestyle that enables you to make healthy choices. To begin a holistic program that will improve your future health, I need to make a comprehensive evaluation of your medical history and history of experience with physical activity. The information provided on this form will allow me to make an important evaluation of your current health status. There are no short cuts to Wellness; it s a process that must begin with a solid foundation. A foundation of Wellness is strong and enduring not weak and short term! Wellness is the right way period. You re now on your way to High-Performance Health. I m looking forward to helping you to help yourself, so let s get moving! In health, Ron Jones Ron Jones (8-7-04) The first wealth is health. --Emerson
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Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for
Welcome to the CANYON WELLNESS PROGRAM!
Welcome to the CANYON WELLNESS PROGRAM! This program is designed to allow you to continue/initiate the pursuit of your health/wellness goals. You may have just completed a course of Physical Therapy or
Patient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated
Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other: