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Medical Questionnaire

Biographical Information:

Todays Date:(mm/dd/yyyy)
Name:
Age: D.O.B:
Address:
City: State: Zip:
Phone Number:(home & work)

Incase of emergency, notify whom:
Name:
Phone number:
Relationship:

Name of Family Physician:
Physician's Phone Number:
Physician's office address:
City: State: zip:
May we contact your physician?

1. Height:(without shoes) Weight:

2. Blood Pressure:

Do you have high blood pressure? Yes No
Have you had high blood pressure in the past? Yes No
Do you often feel faint or have spells of severe dizziness? Yes No
Are you on medication for high blood pressure? Yes No
If yes, what medications are you currently taking?

3. Cholesterol Levels:

Do you know you total cholesterol level? Yes No
If yes, what is it?

Do you know your "good cholesterol" (HDL) level? Yes No
If yes, what is it?

Do you know your "bad cholesterol" (LDL) level? Yes No
If yes, what is it?

Do you know your Triglyceridelevel? Yes No
If yes, what is it?

4. Smoking:

Do you smoke? Yes No
Are you a former smoker? Yes No
If you are a former smoker, when did you quit?
If you are a former smoker, how long did you smoke?
If you are a current smoker, how much do you smoke?

5. Alcohol Use:

Do you use Alcohol? Yes No
If yes, how much per day do you drink?
How much per week?

6. Diabetes:

Do you have diabetes? Yes No
If yes, are you well controlled? Yes No
If yes, what type of diabetes do you have ? Type I Type II
If you do have diabetes and take insulin, are you aware of the precautions you must take if you participate in exercise? Yes No
If you have diabetes, have you discussed with your physician that you wish to participate in exercise? Yes No

7. Heart History:

Have you ever had a heart attack? Yes No
Have you ever had heart surgery? Yes No
Have you ever had angina or chest discomfort? Yes No
Have you ever been diagnosed with a heart murmur, irregular heart rate, and/or a rapid heart beat at rest or during exercise? Yes No
Have you ever had a stress test? Yes No
If yes, what type, what date was it performed, and what were the results?
Have you participated in a cardiac rehab. program? Yes No
Has any physician ever expressed concerns that exercise might not be right for you? Yes No
If yes, please explain?

8. Family History:

Has anyone in your immediate family ever had cardiovascular disease including heart attack, angioplasty, cariac surgery, coronary astery disease, angina, and hypertension? Yes No
If yes, which condition did they have, at what age were they afflicted, and did death occur from this condition?
Has anyone in your family ever had pulmonary disease including asthma, emphysema, and brochitis? Yes No
If yes, which condition did they have, at what age were they afflicted, and did death occur from this condition?
Has anyone in your immediate family ever had cerebrovasculaar disease, including strokes? Yes No
If yes, which condition did they have, at what age were they afflicted, and did death occur from this condition?
Has anyone in your immediate family ever had the following diseases:
Diabetes Yes No
Peripheral Vascular Disease Yes No
Anemia Yes No
Phlebitis or Emboli Yes No
Cancer Yes No
Osteoporosis Yes No
Emotional Disorders Yes No
Eating Disorders Yes No
If you answered yes to one or more of the questions please describe in greater detail the condition they were afflicted with, their age, and if death resulted from their condition?

9. Orthopedic History:

Do you have any serious bone disorder which might hinder your participation in exercise? Yes No
If yes, please explain?
Do you have any serious joint disorder or swelling of the joints which might hinder your participation in exercise? Yes No
If yes, please explain?
Do you have any serious muscle disorder or swelling of the joints which might hinder your participation in exercise? Yes No
If yes, please explain?

10. Medical History:

Have you had or do you currently have any of the following:
Hernia Yes No
Fibromyalgia Yes No
Ulcer Yes No
Loss of a paired Organ(such as a kidney) Yes No
Thyroid disease Yes No
Seizures disorder (such as epilepsy) Yes No
Sickle Cell Anemia Yes No
Anemia Yes No
Cancer Yes No
Asthma Yes No
Emphysema Yes No
Bronchitis Yes No
Shortness of Breath Yes No
Low Back Pain Yes No
Arthritis Yes No
Osteoporosis Yes No
Tendinitis Yes No
Endema or Swelling Yes No
Skin Disorder(s) Yes No
Vertigo Yes No
Psychological Disorder Yes No
Eating Disorder(s) Yes No
If yes, which condition do you have, please explain in greater detail?
11. Females Only:

Pregnancy
Are you pregnant? Yes No
If yes, which trimester? First Second third
Has your physician placed any limitations on you? Yes No
Is this your first pregnancy? Yes No

Menopause
Are you currently going through menopause? Yes No
If yes, at what age did menopause begin?
Are you currently undergoing hormonal replacement therapy? Yes No
If yes, what type of hormonal treatment are you undergoing ?

12. Medications

Are you now on any medications Yes No
If yes, please list any and all medications you presently use and for what purpose you use them?

13. Are you allergic to Aspirin? Yes No

14. Does Aspirin cause you any stomach or intestinal upset, such as ulcers, bleeding, nausea, pain, vomiting, etc.? Yes No
If yes, please explain?

15. OTHER:
Are there any other comments regarding your medical history that you would like to give?