Health Questionaire


Health Questionaire

Name(Required)
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Are you currently under the care of a physician for any reason at all?(Required)
Does your physician know that you are beginning a new exercise program?(Required)
Regular physical activity is enjoyable and healthy, and for most people safe. However, some individuals may have health-related risks that might require them to check with their physician prior to starting an exercise program. To help determine if there is a need for you to see your physician before starting an exercise program, carefully read and answer the following questions. All information will be kept confidential.

Physical Activity Screening Questions

Has your physician ever told you that you have a heart condition?
Do you experience chest pain when you are physically active?
In the past month, have you experienced chest pain when NOT performing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be aggravated by a change in your level of physical activity?
Is your physician currently prescribing medications for your blood pressure or a heart condition?
Do you know of any other reason, through your own physical experience or a doctor’s advice, why you should not participate in a program of physical activity?

General Health History Questions

Have you ever had a stroke?
Do you have diabetes? If yes, do you take medication or currently receive other treatments related to diabetes?
Do you have asthma or another respiratory condition that causes difficulty with breathing?
Do you have any orthopedic conditions that would restrict you in performing physical activity?
Have you ever been told by a physician that you have one of the following?
Do you currently smoke or have you smoked in the past and stopped in the past six months?
Do you currently have back pain or have you had back pain within the past 6 months or felt discomfort that prevented you from carrying out normal daily activities?
Are you pregnant?
Are you currently taking any medications for a health or medical condition?
If you answered yes to any of the above questions it is recommended that you consult with your physician before participating in a physical activity program. Talk to your doctor about what type of activities would be best to begin within the parameters of your physical capability.
Have you ever been injured? If yes please list body part/s with injuries and describe.
Describe your current Physical Activity on the chart below
How long have you exercised regularly?
Which of the following general goals best captures your fitness goals?
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