page 1 Health/Medical History Questionnaire This information is used solely as an aid and will not be released without your knowledge and consent. Name Date Birth date Address Street City State Zip Phone Number: Email Personal Physician: Name: Phone: YES NO Physical Activity Readiness Questionnaire 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? 2. Do you feel pain in your chest when you do physical activity? 3. In the past month, have you had chest pain when you were not doing physical activity? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? 5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by change in your physical activity? 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? If you checked yes for any question #1-#6, you must receive clearance from your physician prior to participating in this exercise program. Please have your physician complete the Physician Clearance Form. I have read this entire document and have answered all of the questions to the best of my knowledge. Last Name, First Name (print) Date Signature
I. Present & Past History Medical History Have you had or do you presently have any of the following conditions? (Check if yes.) Rheumatic fever Recent operation Edema (swelling or ankles) High blood pressure Injury to back or knees Low blood pressure Seizures Lung disease Heart attack Fainting or dizziness Diabetes High cholesterol Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack) nocturnal dyspnea (shortness of breath at night) Shortness of breath at rest or with mild exertion Chest pains Palpitations or tachycardia (unusually strong or rapid heartbeat) Intermittent claudication (calf cramping) Pain, discomfort in the chest, neck jaw, arms, or other areas Known heart murmur Unusual fatigue or shortness of breath with usual activities Temporary loss of visual acuity or speech, or short-term numbness or weakness in one side, arm, or leg Other Family History page 2
II. Medical Conditions Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.) In addition, please identify at what age the condition occurred. Heart attack Heat operation Congenital heart disease High blood pressure High cholesterol Diabetes Other major illness page 3 Explain checked items:
Activity History 1. How were your referred to this program? (Please be specific.) 2. Why are you enrolling in this program? (Please be specific.) 3. Are you presently employed? Yes No 4. What is your present occupational position? 5. Name of company: 6. Have you ever worked with a personal trainer before? Yes No 7. Date of you last physical examination preformed by a physician: 8. Do you participate in a regular exercise program at this time? Yes No ACTIVITY FREQUENCY TIME page 4 9. Can you currently walk 4 miles briskly without fatigue? Yes No 10. Have you ever performed resistance training exercises in the past? Yes No 11. Do you have injuries (bone or muscle disabilities) that may interfere with exercising? Yes No If yes, briefly describe: 12. Do you smoke? Yes No If yes, how much per day and what was your age when you started? Amount per day Age 13. How high is the level of stress in your life? HIGH MODERATE LOW 14. What is your body weight now? What was it one year ago? At age 21 15. Do you consider yourself: 1) At my goal weight/body composition for maintenance 2) At a weight lower than optimal for health and fitness 3) At a weight higher than optimal for health and fitness 16. Do you follow or have you recently followed any specific dietary intake plan, and in general how do you feel about your nutritional habits?
page 5 17. List the medications, nutritional supplements(s)/herbs, etc. you are presently taking. Medication, supplement or herb Dosage Frequency 18. Please list restaurants where you frequently eat and how often you eat out: Who usually prepares food in your household? Where do you typically shop for groceries? 19. List in order your personal health and fitness objectives. a. b. c. *To be filled out together with your fitness professional: GOAL: DATE: DATE ACHIEVED: I fully and accurately completed the above Medical Information section for the Spokane Aerial Performance Arts conditioning and performance program and have no physical condition that would prevent or hinder my participation, other than those disclosed. In the event of any injury or illness while attending SAPA, I authorize SAPA and its employees to administer first aid, transport me to a hospital and initiate medical treatment if necessary. I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS HEALTH QUESTIONAIRE/APPLICATION BY READING THIS BEFORE SIGNING IT. Last Name, First Name (print) Date Medical History Signature Thank you for your time in filling out the form truthfully and completely!
page 6 PHYSICIAN CLEARANCE FORM to be used only if you checked yes for any question #1-#6. Please have your physician complete the following Physician Clearance Form. Dear Dr. Your patient,, has expressed an interest in starting a program that includes intense exercise and conditioning for circus performance arts (including but not limited to silk tissue, Spanish rope, static trapeze, etc), under the guidance of an experienced coach and trainer. Specifically, this includes: a physical fitness program which will include, but not be limited to, progressive resistance training, core fitness training, stretching and flexibility, and silk tissue conditioning. The sessions will last approximately 1 hour and will begin at a moderate to high intensity level. Below is a clearance form to be filled out and signed by you and returned to. If you have any question, please feel free to call me at 509-435-1576. Specifically, your patient has been referred to you due to: Current or past cardiovascular/cardiopulmonary/coronary heart disease High blood pressure Diabetes Heart/Chest pain Fainting or dizziness Other Please complete this clearance form, indicating any exercise limitations or recommendations you may have discussed with your patient and which you and your patient agree to disclose to the coach/trainer. Please complete the form and mail to: 3003 E 32 nd Spokane, WA 99223 My patient,, has been examined by me and DOES have my approval to participate in a progressive exercise program. I understand the physical and physiological stressors of the program and see no reason why the above named person should not participate. My patient,, has been examined by me and DOES NOT have my approval to participate in a progressive resistance program. (If this statement is filled out, the patient will not be admitted into the program.) M.D. DATE Please stamp or print Name/Address/Phone: PHYSICIAN S RECOMMENDATIONS/CONTRADICATIONS