About
Services
Blog
Events
Videos
Photos
Contact
Shop
Medical History Review
***Please complete the entire form. Incomplete forms will not submit!***
Client Information
Client Name:
Date:
Telephone #:
Date of Birth:
Age:
Height:
Weight:
Emergency Contact Information
Emergency Contact:
Relationship:
Address:
City:
State:
Zip:
Emergency Contact Phone:
Physician Information
Are you currently under a physician's care?
YES
NO
Physician's Phone Number:
Specialty:
Date of Last Physical:
Medical History
Have you ever had a stress test? If YES, what were the results?
YES
NO
Do you take any medication on a regular basis? If YES, please list?
YES
NO
Have you been hospitalized recently? If YES, please list?
YES
NO
Do you smoke?
YES
NO
Are you pregnant?
YES
NO
Do you drink alcohol more than 3x's per week?
YES
NO
Is your stress level high?
YES
NO
Level of activity on a scale of 1-10:
Please check all that apply if you have:
High Blood Pressure
High Cholesterol
Diabetes
Have Parents or Siblings Who Had (prior to the age of 55):
Heart Attack
Stroke
High Blood Pressure
High Cholesterol
Known Heart Disease
Rheumatic Heart Disease
Heart Murmur
Chest Pain with Exertion
Irregular Heartbeat or Palpitations
Lightheadedness or Fainting
Unusual Shortness of Breath
Cramping Pains in Legs or Feet
Community & Neighborhood Parks
Emphysema
Other Metabolic Disorders (thyroid, kidney, etc.)
Epilepsy
Asthma
Back Pain (upper, middle, lower)
Other joint pain
Muscle Pain or Injury
No Known Immediate Family Issues
Client/Guardian Signature
Email:
E-Signature:
THANK YOU FOR YOUR CONFIDENCE AND I'M VERY EXCITED TO WORK WITH YOU! LET’S SMASH THESE GOALS ALREADY!
Send Medical History Review