- abnormal blood lipids/ cholesterol. - lightheadedness or fainting with exercise. -heart murmur. - rapid heart beats or palpitations.
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1 health medical questionnaire page 1 name date address- phone (day)- (evening)- sex- -- height- -- weight- date of birth - -age- occupation personal physician - address - _ phone (day)- date of last physical exam- Do you have your physician s consent to participate in an exercise program Were you referred? if yes, by whom? Are you currently taking any prescriptions or medications- - - please list- Medical History Have you had or do you have any of the following: -heart attack -coronary angioplasty -cardiac surgery - chest discomfort during or after exercise - high/low blood pressure - shortness of breath with exercise - abnormal blood lipids/ cholesterol - lightheadedness or fainting with exercise -heart murmur - rapid heart beats or palpitations -diabetes -anemia -asthma -family history -thyroid condition -cancer -other
2 health medical questionnaire page 2 Have you ever had or do you currently have any of the following conditions: Neck -Pinched nerve -Fractures -Sprains/Strains -Surgery -Disc problems -Unexplained pain -Tight musculature Spine/Back -Fracture -Muscle spasm -Scoliosis -Surgery -Pain with lifting -Ruptured/Herniated disc -S-I joint pain -Osteoporosis -Chronic low back pain -Arthritis -Stiffness -Spondylogenic problems -Congenital deformity Pelvis/Hip -Fracture -Groin strain -Subluxation/Dislocation -Tendinitis -Surgery -Contusion/Hip pointer -Bursitis -Leg length discrepancy Thigh -Fracture -Quadriceps strain -Hamstring strain -Surgery -Ruptured muscle -Calcium deposits -Tight I.T. band -Tendinitis
3 health medical questionnaire page 3 Knee/Lower Leg -Fracture -Ligament damage -Strain/Sprain -Patella-femoral pain -Surgery -Subluxation/Dislocation -Tendinitis -Shin splints -Cartilage damage/removal - Limited Range of Motion Ankle/Foot -Fracture -Ligament damage -Compartment Syndrome -Orthotics -Surgery -Tendinitis -Strain/Sprain -Subluxation/Dislocation -Limited Range of Motion _ Shoulder/Clavicle -Fracture -Separation -Arthritis -Tendinitis -Subluxation/Dislocation -Degenerative rotator cuff disease - Limited range of motion -Other Arm -Fracture -Calcium Deposits -Ruptured Muscle Elbow -Fracture -Sprain/Strain -Subluxation/Dislocation -Tendinitis -Surgery -Limited range of motion Hand, Wrist, Fingers -Fracture -Sprain/Strain -Surgery -Arthritis -Carpal Tunnel -Limited range of motion
4 health medical questionnaire page 4 Are you presently receiving or have you received physical therapy- if yes, with whom and when: Are there any other comments you would like to give concerning your health? exercise history and personal goals Are you presently involved in a regular exercise program- if yes, please list activity, duration, frequency and intensity How much time are you able to devote to an exercise program:--- days/week- ---time- What type of physical activities do you like: What do you want your exercise program to do for you: -increase muscular strength -improve cardiovascular fitness -injury prevention -post-rehab conditioning -improve sports performance -reduce health risks -improve flexibility/mobility -reshape and tone body -increase energy level -stop smoking/drinking -reduce stress level -body fat weight loss -weight gain -improve eating habits -other (list)- What can I do for you?
5 health medical questionnaire page 5 lifestyle and nutrition Do you currently smoke- --(if yes, how often) Have you quit smoking-- --(if yes, when) Do you use alcohol- --(if yes, how much and how often)- Do you drink coffee or soda with caffeine- -- (if yes, how much & how often)- Are you presently on a diet- Do you consider yourself-- -overweight -about right -underweight How many meals a day do you usually eat- - How would you describe your nutritional habits:- good fair poor How would you describe your knowledge of nutrition: good fair poor Is your job active or sedentary.- Do you experience a lot of stress in your life- Describe your knowledge of exercise and fitness:- good fair poor How physically fit do you think you are- physical assessment resting blood pressure- resting pulse- THR range- body composition:- female: male: skin fold: triceps- chest- suprailium- abdomen- thigh- thigh- total- total- % body fat % body fat girth measurements (right side of body) upper arm- hips- chest- thigh- waist- calf- Muscular strength/endurance Sit and reach- Push-ups- Chin-ups- Crunches-
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