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Medicalhistory (Southeastern Louisiana University)

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Health & Medical History Questionnaire
Name: ___________________________ W#: ____________________________
Address: __________________________________________________________________
City State Zip
Birthdate (MM/DD/YYYY): __________________ Age: _________
Gender: __________________________ Ethnicity: _______________________
Occupation: _______________________
Physician’s Name: ________________________
Physician’s Phone #: ______________________
Date of last physical exam (MM/DD/YYYY): _________________
Height: ____________ Weight: _________________
Please describe any limitations/restrictions the Program Coordinator should be aware of:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Medications
(Include any over-the-counter medications, prescribed medications, and supplements)
NAME DOSAGE PURPOSE FOR HOW LONG?
Please list any special accommodations or needs:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list any current fitness or sports activities (within the last 3 months):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Which of the following activity levels would you consider yourself as? (Check one)
_____ Sedentary/Inactive- do not participate in formal exercise & not physically active
during the day
_____ Light Physical Activity- activities that you do regularly as part of your day (ex:
walk to and from work for 15 minutes each way, raking leaves for 30 minutes, or playing an easy
game of ping pong for 20 minutes)
_____ Moderate Physical Activity- participating in cardiorespiratory endurance exercise
for 20-60 minutes, for 3-5 days a week (ex: jogging for 30 minutes, 3 days a week, or walking
briskly for 30 minutes, 5 days a week, or weight training, one set of 8 exercises, 2 days a week)
_____ Vigorous Physical Activity- exercising for 20-60 minutes on most days out of the
week, including aerobic exercise, interval training, strength training, and stretching exercises (ex:
running for 45 minutes, 3 days a week, or doing intervals, 2 days a week, or weight training, 3
days per week)
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Medicalhistory (Southeastern Louisiana University)

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Completed 20 July 2020

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