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Community Wellness Exercise Program

Health History Questionnaire

|Date: | | |

|Name: (last) (first) |

|Address: |

|Email Address: |

|Gender: | |Age: |

|Female Male | | |

|Physician’s Name: |

|Physician’s Address: | |Physician’s Telephone: |

Health/ Fitness History

Do you presently exercise a minimum of 3 times per week for at least 20 minutes at a time?

Yes No

If you answered “yes” to the previous question, please specify the activities in which you are involved:

Running/jogging Racket sports Yoga

Brisk walking Light/moderate walking Golf

Weight training Cross-country skiing Tai-Chi

Biking Aerobic dance Swimming

Other: _________________________________________________________

Total minutes engaged in aerobic activity per week:

None 0-20 minutes per week

21-40 minutes per week 41-60 minutes per week

61-80 minutes per week 81-100 minutes per week

101+ minutes per week

Do you now, or have you ever, smoked cigarettes?

Yes No

if you answered “yes” :

How many years did you smoke? ____________________________________

When did you stop smoking? _______________________________________

How many cigarettes did (or do) you smoke in one day? _________________

Do you drink alcoholic beverages?

Yes No

If you answered “yes”:

How many drinks do you have in one day? ______________________

Do you drink coffee or colas with caffeine?

Yes No

If you answered “yes” to the previous question:

How many cups of coffee or other drinks containing caffeine do you consume in one day?_____

Are you now or have you ever been on a diet?

Yes No

If you answered “yes” to the previous question, please explain:

___________________________________________________________________________

Do you consider yourself:

Overweight? Normal weight? Under weight?

How active do you consider yourself? (please select one)

Sedentary Lightly active Moderately active Highly active

MEDICAL HISTORY

Please check any condition(s) or diseases(s) that you now have or have had in the past:

Anemia

Ankle swelling

Arthritis

Asthma

Back problems

Broken bones

Bronchitis

Bursitis

Cardiac surgery

Cancer

Chest discomfort

Chronic cough

Cold hands or feet

Diabetes

Emotional disorders

Emphysema

Epilepsy or seizures

Extra, skip, rapid heartbeat

Fatigue or lack of energy

Foot problems

Heart attack, bypass

Heart murmurs

Heart palpitations

Hernia

High blood pressure

Increased anxiety/depression

Knee problems

Light-headedness or fainting

Limited range of motion

Low blood pressure

Migraine/recurrent headache

Neck problems

Peripheral vascular disease

Phlebitis or emboli

Pneumonia

Rheumatic fever

Shoulder problems

Stomach/intestinal problems

Strained/sprained ligaments

Strained/Sprained tendons

Stroke

Swollen, stiff, painful joints

Trouble sleeping

Ulcers

Unusual shortness of breath

Other: please use lines below

If you checked any of the conditions listed above, please explain:

Please list any medications (prescribed or over the counter) and supplements you are presently taking:

Please list any illnesses, hospitalizations or surgical procedures within the past 2 years:

Please list the date of your last physical examination and describe the results:

FAMILY MEDICAL HISTORY

Please check any conditions or diseases that any of your blood relatives (parents, grandparents, aunts, uncles or siblings) have had:

Congenital heart disease Coronary artery disease

Coronary operations Diabetes

Elevated cholesterol Heart attack

High blood pressure Stroke

Cancer

FITNESS GOALS

What are your goals for joining the community wellness center? (please check all that apply)

To lose weight To improve cardiovascular fitness

To improve flexibility To improve muscle strength and endurance

To reduce low back pain To reduce stress

To stop cigarette smoking To lower cholesterol

To improve nutrition To feel better overall

Other: ____________________________________________________________

Emergency Contact Information Form

This information will be extremely important in the event of an accident or medical

emergency.

Please be sure to sign and date this form

Primary Emergency Contact Name: _______________________________________________________

Relationship: ______________________________

Phone: Home: ________________________ Cell: ______________________

Secondary Emergency Contact Name: ___________________________________________________ Relationship: ______________________________

Phone: Home: ________________________ Cell: ______________________

Signature: ___________________________________________ Date: ______________________

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