The University of Texas Fitness Institute of Texas Health and Fitness Screening Questionnaire. Name Date Sex Date of Birth Address Phone UTEID
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1 The University of Texas Fitness Institute of Texas Health and Fitness Screening Questionnaire Name Date Sex Date of Birth Address Phone UTEID Please answer the following questions to the best of your knowledge by checking either yes or no. Section 1: Yes No Unknown 1. Has a doctor ever said that you have a heart condition and recommended only medically supervised physical activity? 2. Do you have chest pain brought on by physical activity? 3. Have you developed chest pain in the last month when not doing physical activity? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? 5. Has a doctor ever recommended medication for your blood pressure or a heart condition? 6. Are you aware, through your own experience, a doctor s advice, or any other physical reason that would prohibit you from engaging in physical activity? Section 2: 7. Do you smoke or have you quit within the last six months? 8. Is your blood cholesterol level >240 mg/dl? 9. Do you have a close relative who has had a heart attack or sudden death before age 55 (father or brother) or age 65 (mother or sister)? 10. Are you diabetic or taking medicine to control blood sugar? 11. Are you physically inactive ( less than 30 minutes of physical activity 3 days per week)? Section 3: 12. Have you ever experienced pain or discomfort in the chest, neck, jaw, arm, or other areas of your body that indicate lack of blood flow to the heart? 13. Do you ever experience shortness of breath at rest or with mild physical activity? 14. Do you ever experience shortness of breath while lying flat or wake up in the middle of the night with shortness of breath? 15. Do you currently have swelling of your ankles? 16. Do you ever experience palpitations of your heart or a very rapid heart rate with mild exertion? 17. Do you ever experience unusual fatigue or shortness of breath with usual daily activities? 18. Do you ever experience pain in your legs while exercising that is relieved by rest? Section 4: 19. Do you have a bone or joint problem that could be aggravated by engaging in physical fitness testing?
2 20. Are you currently experiencing or have you recently experienced any muscle or joint pain? 21. Do you now have or have you ever had asthma? Yes No Unknown 22. Do you now have or have you ever had: a. Coronary heart disease, heart attack, coronary artery surgery b. Angina c. High blood pressure d. Peripheral vascular disease e. Stroke f. Diabetes g. Thyroid problems h. Hepatitis i. Arthritis j. Gout k. Headaches that are chronic and severe l. Head injury or epilepsy m. Abdominal pain, hernia, or G.I. bleeding n. Kidney problems or discomfort when urinating o. Tendency to bleed or bruise easily p. Anemia q. Lung problems r. Liver problems 23. Have you been diagnosed by your doctor as having a heart murmur? 24. Have you donated blood or lost an equivalent amount of blood from injury within the past 2 weeks? 25. Are you now or have you been pregnant in the last month? 26. Have you recently been ill or injured? If yes, please describe: 28. Are you currently taking any physician prescribed medications for the following conditions. If yes, list the medications. Medication Name of Medication -Heart medicine -Blood pressure medicine -Hormones -Medicine for breathing/lungs -Insulin -Other medicine for diabetes -Arthritis medicine -Medicine for depression -Medicine for anxiety -Thyroid medicine -Medicine for ulcers -Painkiller medicine -Allergy medicine -Other 29. Are you currently taking any over the counter medications? Please list these medications: 30. For females taking the DEXA test: -- Are you premenopausal
3 Have you previously been tested at the Fitness Institute of Texas? Section 5: 1. How satisfied are you with your current weight/body composition? a. Very satisfied b. Satisfied c. Somewhat satisfied/somewhat dissatisfied d. Dissatisfied e. Very dissatisfied 2. If you are not satisfied or very satisfied with your weight/body composition, what would make you satisfied? a. To gain weight and/or muscle b. To lose 5-10 lbs c. To lose lbs d. To lose lbs e. To lose 25 or more lbs 3. How many minutes of moderate to vigorous intensity aerobic exercise do you do each week? (Walking fast, joggin, basketball, water aerobics, bike riding, swimming, tennis, pushing a lawn mower, etc.) a. None b hour c hours d hours e hours f. >3.5 hours 4. How many minutes of resistance or weight training type exercise do you do each week? a. None b hour c hours d hours e hours f. >3.5 hours 5. How long have you been exercising regularly? a. I do not exercise b. Less than 3 months c. 3 6 months d. 6 months 1 year e. 1 2 years f. 2 5 years g. >5 years
4 6. What is your primary fitness related goal? a. Lose weight/decrease body fat b. Gain muscle/strength c. Improve cardiovascular fitness d. Improve flexibility e. Be/stay healthy f. Aesthetic reasons g. Athletic performance h. I do not have a goal 7. Do you have any history of disordered eating? a. Yes b. No
5 For staff use only: Based on the answers to questions in sections 1, 2, and 3 of the Health and Lifestyle Questionnaire, determine and record which tests the participant can partake in. Circle the one that applies to the participant Section 1: Questions PAR- Q If the participant answers yes to any of questions 1-6, they need to see a physician before being tested. cannot be tested (no strength, power, or aerobic tests) Section 2: Questions 7-11 CAD risk factors Low risk: Young individuals ( men < 45; women < 55) who are asymptomatic and answer yes to one or fewer in questions maximal GXT Moderate risk: Older individuals (men 45; women 55) or those who answer yes to two more in submaximal GXT questions (strength 6 reps) Section 3: Questions Major signs/symptoms * These symptoms must be interpreted in the clinical context in which they appear because they are not all specific for cardiovascular, pulmonary, or metabolic disease. High risk: Individuals who answered yes to one or more in questions or have known cardiovascular, pulmonary, or metabolic disease. cannot be tested (no strength, Individuals who have blood pressure of power, or 150/95 mmhg or over aerobic tests) Section 4: Questions Health questions If the participant answers yes to certain questions in this section, a personal interview will be conducted to determine which tests that he or she can participate in.
The University of Texas Fitness Institute of Texas Health and Fitness Screening Questionnaire
The University of Texas Fitness Institute of Texas Health and Fitness Screening Questionnaire ID Please answer the following questions to the best of your knowledge by checking either yes or no. Section
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Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
INITIAL MEDICAL PACKET
P a g e 1 INITIAL MEDICAL PACKET Name: Sport: Date: Last First Middle SSN: - - DOB: / / Age: Cell Phone: ( ) - Home Phone: ( ) - Family Physician: Phone: ( ) - Emergency contact: Name: Phone: ( ) - Relationship:
Patient Medical History
Date: The PMA Metabolic and Bariatric Weight Management Center 410 West Linfield-Trappe Road, Suite 100 Limerick, PA 19468 (610) 495-2338 Patient Medical History Name: Date of Birth: Age: Female Male ALLERGIES:
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Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant