Medical History Review

Client Name:

Date:

Telephone #:

Date of Birth:

Age:

Height:

Weight:

Emergency Contact:

Relationship:

Address:

City:

State:

Zip:

Emergency Contact Phone:

Are you currently under a physician's care?
YES NO

Physician's Phone Number:

Specialty:

Date of Last Physical:

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

Email:

E-Signature:

Medical History Review

Client Information

Emergency Contact Information

Physician Information

Medical History

Client/Guardian Signature

THANK YOU FOR YOUR CONFIDENCE AND I'M VERY EXCITED TO WORK WITH YOU! LET’S SMASH THESE GOALS ALREADY!