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Health History Questionnaire

Please answer the following questions to the best of your ability. For the following questions, unless otherwise indicated, select the single best choice for each question. As is customary, all of your responses are completely confidential and may only be used in group summaries and/or reports. All information collected is subject to the Privacy Act of 1974. If you have any physical handicaps or limitations that would require special assistance with this questionnaire, please let the trainer or coach know. This form is in accordance with the American College of Sports Medicine guidelines for risk stratification when followed correctly by your trainer. Your trainer should be certified with a national organization in order to use these forms correctly. 

1) Have you ever had a definate or suspected heart attack or stroke?
2) Have you ever had coronary bypass surgery or any othe type of heart surgery?
3) Do you have any other cardiovascular or pulmonary (lung) disease (OTHER THAN asthma, alergies, or mitral valve prolapse)?
4a) Do you have a history of Diabetes?
4b) Do you have a history of thyroid disease?
4c) Do you have history of Kidney Disease?
4d) Do you have history of liver disease?
5) Have you ever been told by a health professional that you have had an abnormal resting or exercise (treadmill) electrocardiogram (EKG)?

If you answered YES to any of the above questions, please describe:

7) Do you currently have any of the following: 

a) pain or discomfort in the chest or surrounding areas that occurs when you engage in physical activity?
b) shortness of breath?
c) unexplained dizziness or fainting?
d) difficulty breathing at night except in upright position?
e) swelling of the ankles (recurrent and unrelated to injury)?
f) heart palpitations (irregularity or racing of the heart on more than one occasion)?
g) pain in the legs that causes you to stop walking (claudication)?
h) known heart murmur?
Have you discussed any of the above YES answers with your personal physician?
8) Are you pregnant or is it likely that you could be pregnant at this time?
9) Have you had surgery or been diagnosed with any disease in the past 3 months?
10) Have you had high blood cholesterol or abnorml lipids within the past 12 months or are you taking medication to control your lipids?
11) Do you currently smoke cigarettes or have you quit within the past 6 months?
12) Have your father or brother(s) had heart disease prior to age 55 OR mother or sister(s) had heart disease prior to age 65?
13) Within the past 12 months, has a health professional told you that you have high bloodpressure?
14) Curently, do yo have high blood pressure or within the past 12 months, have you taken any medicines to control your blood pressue?
15) Have you ever been told by a health professional that you have fasting blood glucose greater than or equal to 110 mg/dl?

16) Describe your regular physical activity or exercise program:  (Type, Frequency, Duration, Intensity.)

17) If you answered YES to any of questions 7-15, please describe:

18) Are you currently under any treatment for any blood clots?
19) Do you have problems with bones, joints, or muscles that may be aggravated with exercise?
20) Do you have any back/neck problems?
21) Have you been told by a health professional that you should not exercise?
22) Are you currently being treated for any other medical condition by a physcian?
23) Are there any other complications (mitral valve prolapse, epilepsy, history of rheumatic fever, asthma, cancer, anemia,hepatitis, etc.) that may HINDER your ability to exercise?
24) During the past six months, have you experienced any UNEXPLAINED weight gain or loss (greate than 10 pounds for no known reason)?

25) If you have answered YES to any of questions 18-24, please describe:

26) Please list below all prescription and over-the-counter medications you are currently taking:

If so, please list: 

27) Are there any medicines that your physician has prescribed to you in the last 12 months which your are currently not taking?

I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factory in the development of my fitness/wellness program. I understand that certain medical or physical conditions which are known to me, but that I do not disclose to my trainer, may result in serious injury to me. If any of the above conditions change, I will immediately inform my trainer of those changes. I, knowingly and willingly, assume all risks of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the attached questionnaire. I also understand that in order to properly risk stratify my Health History Questionnaire, my trainer should have a minimum of a national certification as a personal trainer.

Your form has been submitted successfully. 

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