Health Questionaire Health Questionaire Name(Required) First Last Address(Required) Phone #(Required)Emergency Contact(Required)Phone #(Required)Doctor's Name Date of last physical MM slash DD slash YYYY Are you currently under the care of a physician for any reason at all?(Required) Yes No Does your physician know that you are beginning a new exercise program?(Required) Yes No 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 QuestionsHas your physician ever told you that you have a heart condition? Yes No Do you experience chest pain when you are physically active? Yes No In the past month, have you experienced chest pain when NOT performing physical activity? Yes No Do you lose balance because of dizziness or do you ever lose consciousness? Yes No Do you have a bone or joint problem that could be aggravated by a change in your level of physical activity? Yes No Is your physician currently prescribing medications for your blood pressure or a heart condition? Yes No 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? Yes No General Health History QuestionsHave you ever had a stroke? Yes No Do you have diabetes? If yes, do you take medication or currently receive other treatments related to diabetes? Yes No Do you have asthma or another respiratory condition that causes difficulty with breathing? Yes No If yes, please describe: Do you have any orthopedic conditions that would restrict you in performing physical activity? Yes No If yes, please describe: Have you ever been told by a physician that you have one of the following? high blood pressure elevated blood lipids, including high cholesterol cardiovascular disease cancer ther health/medical condition Do you currently smoke or have you smoked in the past and stopped in the past six months? Yes No 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? Yes No Are you pregnant? Yes No Are you currently taking any medications for a health or medical condition? Yes No If yes, please indicate which medications you are taking. 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. Abdomen Eye Leg Arm Foot/Toes/Ankle Mouth/Teeth Back Hand/Fingers Neck Chest Head/Skull Nose Ear Knee Other Date of injury Describe Injury Describe your current Physical Activity on the chart below Inactive-less than 30 minutes activity on a maximum of 3 days per week Slightly Active-more than 30 minutes on 3 days per week Moderately Active-more than 30 minutes of physical activity on most, if not all, days of the week Very Active-more than 45 minutes of physical activity on all days of the week How long have you exercised regularly? I do not Exercise Regularly Less than 1 Year 1 to 2 Years 2 to 5 Years 5 to 10 Years More Than 10 Years Which of the following general goals best captures your fitness goals? General Toning Core Strengthening Cardiovascular Conditioning Sport Specific Cardiac Rehabilitation Weight Reduction Release Consent(Required)I know of no physical or medical condition that I or my physician feel could be aggravated by my using the equipment or facilities or participating in activities sponsored by this club. I agree to advise club management in writing if any of the above information changes or if my doctor advises me to stop, reduce or otherwise adjust my exercise regimen at this facility. I agree.Signature(Required) Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
