Health History Questionnaire
Name_____________________________
Course_____________________
Email_____________________________
Phone_____________________
Banner ID #__________________
Age___________
Gender
M
F
Regular physical activity is safe for most people. However, some individuals
should check with their doctor before they start an exercise program. To help us
determine if you should consult with your doctor before starting this class, please
read the following questions carefully and answer each one honestly. All
information will be kept confidential. Please check YES or NO:
YES
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NO
____ 1.
Do you have a heart condition? Specify type_____________
____ 2.
Have you ever experienced a stroke? When?____________
____ 3.
Do you have epilepsy? If so, how long?________________
____ 4.
Are you pregnant? If yes, which trimester?_____________
____ 5.
Do you have diabetes? If yes, what type?______________
____ 6.
Do you have emphysema?
____ 7.
Do you feel pain in your chest when you engage in physical
activity?
____ 8.
Do you have chronic bronchitis?
____ 9.
In the past month, have you had chest pain when you were
NOT participating in physical activity?
____ 10.
Do you ever lose consciousness or do you ever lose control
of your balance due to chronic dizziness?
____ 11.
Are you currently being treated for a bone or joint problem
that restricts you from engaging in physical activity? If yes, explain:
_______________________________________________________
____ 12.
Has a physician ever told you or are you aware that you
have high blood pressure?
____ 13.
Has anyone in your immediate family
(parents/brothers/sisters) had a heart attack, stroke, or cardiovascular
disease before age 55?
____ 14.
Has a physician ever told you or are you aware that you
have a high cholesterol level?
____ 15.
Do you currently smoke? If yes, how many
packs/day?______________
____ 16.
Are you currently taking any medication or supplements?
Please list the medication(s) and its purpose______________________
__________________________________________________________
__________________________________________________________
Which of the following indicates your current level of physical activity?
_____ Less than 1 hour per week
_____ 3-5 hours/week
_____ 1-3 hours/week
_____ more than 5 hours/week
Please list your current activities:_____________________________________
What are your specific fitness goals? (Indicate
_____ Increase strength and endurance
_____ Improve cardiovascular fitness
_____ Reduce body fat
_____ Exercise regularly
_____ Sports conditioning
all that apply)
_____ Improve flexibility
_____ Improve muscle tone
_____ Increase muscle mass
_____ Injury rehabilitation
_____ Other_________________
What are your specific health goals? (Indicate all that apply)
_____ Reduce stress
_____ Improve nutritional habits
_____ Control blood pressure
_____ Control cholesterol
_____ Stop smoking
_____ Reduce back pain
_____ Feel better overall
_____ Increase health awareness
_____ Other (please specify)__________________________________________
Why are you taking this class?_________________________________________
_________________________________________________________________
I understand that participation in a supervised exercise program has been
associated with several health benefits including lower total cholesterol, blood
pressure, obesity, and risk of cardiovascular events along with increased
cardiovascular fitness, muscle strength, and endurance. Risks involved with
increased physical activity include muscular fatigue, soreness, strains, and a
slight increased risk of sudden death.
I have read, understood, and completed this questionnaire and verify that I have
answered all questions to the best of my ability. Any questions that I had were
answered to my full satisfaction. I consent to participate in this exercise class
without medical clearance from my physician and give my permission to use the
information included in this questionnaire to Northeast Lakeview College and its’
representatives in a confidential manner.
Name (print)____________________________
Date_________________
Signature_________________________________________