Health History Questionnaire

This is a more in depth health questionnaire to assess any physical or medical conditions which need to be considered when planning your training.

Full Name*

Height*

Weight*

Birth Specified Gender

Male
Female

Age*

Date of Birth*

Date of Birth

Address*

Telephone*

Emergency Contact*

Email address*

1. Have you ever had a definite or suspected heart attack or stroke?

Yes
No

2. Have you ever had coronary bypass surgery or any other type of heart surgery?

Yes
No

3. Do you have any other cardiovascular or pulmonary (lung) disease (other than asthma, allergies, or mitral valve prolapse)?

Yes
No

4. Do you have a history of diabetes, thyroid, kidney or liver disease?

Yes
No

5. Have you ever been told by a health professional that you have an abnormal resting or exercise (treadmill) electrocardiogram (EKG)?

Yes
No

6. If you answered yes to any of questions 1-5 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

Yes
No

b. Shortness of breath

Yes
No

c. Unexplained dizziness or fainting

Yes
No

d. Difficulty breathing at night except in an upright position

Yes
No

e. Swelling of the ankles (recurrent and unrelated to injury)

Yes
No

f. Heart palpitations (irregularity or racing of the heart on more than one occasion)

Yes
No

g. Pain in the legs that causes you to stop walking

Yes
No

h. Known heart murmur

Yes
No

Have you discussed any of the above with a healthcare professional?

Yes
No

8. Are you pregnant or is it likely that you could be pregnant at this time?

Yes
No

9. Have you had surgery or been diagnosed with any disease in the past 3 months?

Yes
No

10. Have you had high cholesterol or abnormal lipids within the past 12 months or are you taking any medication to control your lipids?

Yes
No

11. Do you currently smoke or have quit within the past 6 months?

Yes
No

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?

Yes
No

13. Within the past 12 months, has a health professional told you that you have high blood pressure?

Yes
No

14. Currently, do you have high blood pressure or within the past 12 , have you taken any medicines to control your blood pressure?

Yes
No

15. Have you ever been told by a health professional that you have a fasting blood glucose greater than or equal to 110 mg/dl?

Yes
No

16. Describe your regular physical activity or exercise program (include type. frequency, duration & intensity):*

17. if you have answered YES to any of questions 7-16 please describe:*

18. Are you currently under any treatment for blood clots?

Yes
No

19. Do you have problems with bones, joints, or muscles that may be aggravated with exercise?

Yes
No

20. Do you have any back/neck problems?

Yes
No

21. have you been told by a health professional that you should not exercise?

Yes
No

22. Are you currently being treated for any other medical condition by a health professional?

Yes
No

23. Are there any other conditions (mitral valve prolapse, epilepsy, history of rheumatic fever, asthma, cancer, anemia, hepatitis, etc.) that may hinder your ability to exercise?

Yes
No

24. During the past six months, have you experienced any unexplained weight loss or gain (greater than 10 pounds for no known reason)?

Yes
No

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

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

Please list any medicines that a health care professional has prescribed to you in the past 12 months that you 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 factor in the development of my coaching program. I understand that certain medical or physical conditions that are known to me, but that I do not disclose to my coach may result in serious injury to me. If any of the above conditions change, I will immediately inform my coach of these 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.

Clients Signature (Digitally just first initial and surname)*

Date Field