Health Medical History

Name First Last
Date of birth / MM / DD YYYY
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone (Home) - ### - ### ####
Phone (Work) - ### - ### ####
Email
Phone (Cell) - ### - ### ####
Emergency Contact
Name First Last
Relationship
Phone Number - ### - ### ####
Physical activity should not pose any problem or hazardto the majority of people. The following questions are designed to identify the small number of adults for whom physical activity might beinappropriate or those who should seekmedical advice prior to initiating a fitness program or other change in their physical activity levels.
Are you over age 55 and/or not accustomed to vigorous exercise?

Are you over age 55 and/or not accustomed to vigorous exercise? Yes No
Have you ever been diagnosed with Type I or Type II Diabetes?

Have you ever been diagnosed with Type I or Type II Diabetes? Yes No
Have you had any major or minor surgery in the past 3 months?

Have you had any major or minor surgery in the past 3 months? Yes No
Have you been hospitalized in the last 2 years? If so, when and for what reason?

Have you been hospitalized in the last 2 years? If so, when and for what reason? Yes No
Are you currently, or have you in the past, ever seen a chiropractor or physical therapist for any condition? If yes, when and for what condition?

Are you currently, or have you in the past, ever seen a chiropractor or physical therapist for any condition? If yes, when and for what condition? Yes No
Do you ever experience unexpected shortness of breath, or labored breathing, with or without pain? If yes, describe under what conditions

Do you ever experience unexpected shortness of breath, or labored breathing, with or without pain? If yes, describe under what conditions Yes No
Do you currently, or have you ever, experienced unexplained heart palpitations or been diagnosed with a heart murmur or irregular heartbeat?

Do you currently, or have you ever, experienced unexplained heart palpitations or been diagnosed with a heart murmur or irregular heartbeat? Yes No
ave you ever been diagnosed with high blood pressure? If yes, when?

ave you ever been diagnosed with high blood pressure? If yes, when? Yes No
Do you know what your blood pressure normally is? If yes, please state

Do you know what your blood pressure normally is? If yes, please state Yes No
Do you currently smoke? If yes, how many cigarettes per day?

Do you currently smoke? If yes, how many cigarettes per day? Yes No
Did you ever smoke? If yes, how long ago did you quit?

Did you ever smoke? If yes, how long ago did you quit? Yes No
Is there any history of heart disease (prior to age 55) in your immediate family? If yes, explain.

Is there any history of heart disease (prior to age 55) in your immediate family? If yes, explain. Yes No
Do you know your cholesterol levels? If so, please state

Do you know your cholesterol levels? If so, please state Yes No
Do you receive regular annual physical exams from your primary care physician? Date of last exam:

Do you receive regular annual physical exams from your primary care physician? Date of last exam: Yes No
Do you have any pain, discomfort,or known current or previous injury to any of the following areas:
Right or left knee Right or left shoulder Right or left elbow Right or left wrist Right or left ankle Right or left hip Back or neck
If you checked “Yes” to any of the above, please explain the nature of your pain and/or injury. Do certain activities or conditions aggravate the pain and/or injury?
Are there any other health/medical/injury conditions that your trainer should be aware of?
Please list any prescription medications or over-the-counter medications or supplements you currently take:
I the undersigned First Last
certify that I understand the foregoing questions and my answers are true and complete. I also understand that if this information changes in any way in the future, it is my responsibility to notify my personal trainer, and that I assume the risk for any changes in my medical condition that might affect my ability to exercise.

Before beginning a new fitness program or other significant change in your physical activity levels, you are advised to consult withyour physician or primary health care provider. Only a physician or qualified health care provider is able to diagnose and prescribe treatment for specific health conditions.

I acknowledge that I haveread the foregoing statements and fully understand the content thereof, and that if I choose not to consult with my physician or primary health care provider, I do so at my own risk.
Draw your signature into the box below.

Clear
Parent or Legal Guardian (if participant is under 18) First Last
Today's Date / MM / DD YYYY

Health Medical History

Health Medical History

Emergency Contact

If you checked “Yes” to any of the above, please explain the nature of your pain and/or injury. Do certain activities or conditions aggravate the pain and/or injury?