HEALTH-HISTORY QUESTIONNAIRE

 
Name *
Name
Date *
Date
Sex *
Physician’s Phone
Physician’s Phone
Person to contact in case of emergency:
Person to contact in case of emergency:
Section 1
Do you now have, or have you had in the past:
1. History of heart problems, chest pain, or stroke *
2. Elevated blood pressure *
3. Any chronic illness or condition *
4. Difficulty with physical exercise *
5. Advice from physician not to exercise *
6. Recent surgery (last 12 months) *
7. Pregnancy (now or within last 3 months) *
8. History of breathing or lung problems *
9. Muscle, joint, or back disorder, or any previous injury still affecting you *
10. Diabetes or metabolic syndrome *
11. Thyroid condition *
12. Cigarette smoking habit *
13. Obesity [body mass index (BMI) ≥30 kg/m2] *
14. Elevated blood cholesterol *
15. History of heart problems in immediate family *
16. Hernia, or any condition that may be aggravated by lifting weights or other physical activity *
Section 2