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Health/Medical Questionnaire
Date: _________________________
Name: _____________________________ Date of birth: ______________ Soc. Sec. #: __________________
Address: _______________________________________________________________________________________
Street City State Zip
Phone (H): ____________________ (W): ____________________ E-mail address: __________________________
In case of emergency, whom may we contact?
Name: ______________________________________ Relationship: _____________________________________
Phone (H): ________________________________________ (W): _______________________________________
Personal physician
Name: __________________________________ Phone: ____________________ Fax: ____________________
Present/Past History
Have you had OR do you presently have any of the following conditions? (Check if
yes
.)
___ Rheumatic fever
___ Recent operation
___ Edema (swelling of ankles)
___ High blood pressure
___ Injury to back or knees
___ Low blood pressure
___ Seizures
___ Lung disease
___ Heart attack
___ Fainting or dizziness with or without physical exertion
___ 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 with or without physical exertion
___ 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 of
your body
___ Other
Family History
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 arrhythmia
___ Heart attack
___ Heart operation
___ Congenital heart disease
___ Premature death before age 50
___ Significant disability secondary to a heart condition
___ Marfan syndrome
___ High blood pressure
___ High cholesterol
___ Diabetes
___ Other major illness _________________________
From NSCA, 2012,
NSCA’s essentials of personal training,
2nd ed., J. Coburn and M. Malek (eds.), (Champaign, IL: Human Kinetics).