Fillable 6- Sample Health History Questionnaire

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6- Sample Health History Questionnaire

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©2014 AMERICAN COUNCIL ON EXERCISE
@
Name _____________________________________________________________________________ Date _______________________
Age_________________ Sex q M q F
Physician’s Name______________________________________________Physician’s Phone ( ___________ )__________________________
Person to contact in case of emergency:
Name ____________________________________________________________________________ ________________ Phone _________________________
Are you taking any medications, supplements, or drugs? If so, please list medication, dose, and reason.
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Does your physician know you are participating in this exercise program?
_____________________________________________________________________________________________________________________________________
Describe any physical activity you do somewhat regularly.
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
Do you now have, or have you had in the past: Yes No
1. History of heart problems, chest pain, or stroke q q
2. Elevated blood pressure q q
3. Any chronic illness or condition q q
4. Difficulty with physical exercise q q
5. Advice from physician not to exercise q q
6. Recent surgery (last 12 months) q q
7. Pregnancy (now or within last 3 months) q q
8. History of breathing or lung problems q q
9. Muscle, joint, or back disorder, or any previous injury still affecting you q q
10. Diabetes or metabolic syndrome q q
11. Thyroid condition q q
12. Cigarette smoking habit q q
13. Obesity [body mass index (BMI) ≥30 kg/m
2
] q q
14. Elevated blood cholesterol q q
15. History of heart problems in immediate family q q
16. Hernia, or any condition that may be aggravated by lifting weights or other physical activity q q
HEALTH-HISTORY
QUESTIONNAIRE
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6- Sample Health History Questionnaire

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Completed 31 January 2022

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