Www.calverthealthmedicine.org
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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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