Health History Form
Full Name:
*
Gender:
*
Male
Female
Birthdate:(Must be format mm-dd-yyyy)
*
__________
Please read each question carefully and indicate Yes or No by checking appropriate box:
Do you currently participate in any physical activity?
*
Yes
No
If YES explain:
Do you have a history of heart problems, chest pain or stroke?
*
Yes
No
If YES explain:
Do you have a family history of heart problems? If yes, Explain.
*
Yes
No
If YES explain:
Do you have High blood pressure?
*
Yes
No
If YES explain:
Do you have any chronic illness or condition?
*
Yes
No
If YES explain:
Do you have difficulty with physical exercise?
*
Yes
No
If YES explain:
Have you recently had surgery?
*
Yes
No
If YES explain:
Are you, or have you been pregnant within the last 3 months?
*
Yes
No
If YES explain:
Do you have a history of breathing or lung problems?
*
Yes
No
If YES explain:
Do you have muscle or joint problems or any injuries?
*
Yes No
If YES explain:
Do you have Diabetes or a thyroid condition?
*
Yes
No
If YES explain:
Do you have a cigarette smoking habit?
*
Yes
No
If YES explain:
Do you have a hernia?
*
Yes
No
If YES explain:
Do you ever feel weak, fatigued, or sluggish?
*
Yes
No
If YES explain:
Submit
Should be Empty: