Health History Questionnaire
start
 
First and Last Name *

 
Age *

 
Date of Birth *

 
Address. Street. City/State/Zip *

 
Home Phone *

 
Work Phone *

 
Cell Phone *

 
Occupation & Place of Employment *

 
Marital Status *


 
Spouse's name

 
Education (check highest level) *


 
Ethnicity

 
Personal Physician's Name

 
Personal Physician's Location

 
Reason for last doctor visit?

 
Date of last physician exam

 
Have you previously been tested for an exercise program?

     
 
Location of Test and Name of Exercise Professional

 
Person to contact in case of an emergency *

 
Phone # of Emergency Contact *

 
Relationship of Emergency contact.

 
Have you had: *

a heart attack?
     
 
Have you had: *

heart surgery?
     
 
Have you had: *

cardiac catheterization?
     
 
Have you had: *

coronary angioplasty (PTCA)?
     
 
Have you had: *

pacemaker / implantable cardiac defibrillation / rhythm disturbance?
     
 
Have you had: *

heart valve disease?
     
 
Have you had: *

heart failure?
     
 
Have you had: *

heart transplantation?
     
 
Have you had: *

congenital heart disease?
     
 
Have you had: *

other heart condition not listed?
     
 
Please List any other heart conditions that were not listed if any.

 
Have you experienced: *

chest discomfort with exertion?
     
 
Have you experienced: *

unreasonable breathlessness?
     
 
Have you experienced: *

dizziness, fainting, or blackouts?
     
 
Have you experienced: *

ankle swelling?
     
 
Have you experienced: *

unpleasent awareness of a forceful or rapid heart rate?
     
 
Do you take any heart medications? *

     
 
List heart medications & amount below. *

 
Do you have:

*

diabetes?
     
 
Do you have: *

asthma or other lung disease?
     
 
Do you have: *

burning or cramping sensation in Lower legs when walking short distance?
     
 
Do you have: *

musculoskeletal problems that limit your physical activity?
     
 
Do you have: *

concerns about the safety of exercise?
     
 
Are you: *

pregnant?
     
 
If you marked any of the previous questions yes, consult your physician or other appropriate health care provider before engaging in exercise or physical activity. You may need to use a facility with a medically qualified staff member.

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