Campus Wellness
MEDICAL HISTORY
Name:
Sex:
Date of Birth:
M
F
Home Phone #:
Mobile/Work Phone #:
Home Address:
Occupation:
SSN#:
GVSU Employee Group:
Insurance Plan:
Physician or Provider:
Phone #:
Address:
Emergency Contact:
Relation:
Phone #1:
Phone #2:
1. Have you ever been diagnosed or actually treated for any of the following heart-related problems?
NO
YES
WHEN
High blood pressure
Angina (chest pain)
Myocardial infraction (heart attack)
Heart disease or heart rhythm problems
Valvular problems (mitral valve prolapse)
Heart murmur
Comments:
2. Have you ever experienced any of the following signs and/or symptoms?
NO
YES
WHEN
Severe shortness of breath or rapid
heart rate with mild or normal activity
Edema/ankle swelling
Severe dizziness and/or fainting
Claudication/severe muscle cramps
with physical activity (especially in legs)
Hypoglycemia/low blood sugar
Long-term fatigue without being sick
Comments:
3. Do you have asthma or any other pulmonary problems?
NO
YES
NO
YES
Comments:
4. Have you had any surgeries as a result of an injury?
Body region and when:
Comments:
Rehabilitation:
NO
YES
5. Do you have a neuromuscular disorder, rheumatoid disorder or muscle disorder that
is worsened by physical activity?
NO
YES
If so, explain the problem, body region affected and when the pain occurs?
6. Has anyone in your immediate family been diagnosed with any of the following?
NO
YES
Relation
Age of Onset
Heart attack/heart problems
High blood pressure
Diabetes, Type 1 or 2
Comments:
7. List any drugs, pills, and over-the-counter or prescription medications that you are currently taking:
Medications, Pills or Supplements
Prescribed For
Taken Since
1.
2.
3.
Comments:
8. Do you known of any other medical, physical or emotional conditions or problems that would require
modified exercise program? Explain:
9. Smoking status:
Never Smoked
Used to Smoke
*Packs per day (amount):
a
Currently Smoke*
*Number of years smoked:
If you quit smoking, what year did you quit:
Do you currently use cigars, pipes or smokeless tobacco products (i.e., chew, snuff)?
Have you ever been diagnosed with chronic bronchitis or emphysema:
NO
NO
YES
YES
If yes, explain:
10. How many days per week do you currently exercise:
5-7
How long do you typically exercise:
20-29 min.
30+ min.
At what level or intensity do you typically exercise:
3-4
vigorous
2-1
10-19 min .
NONE
< 10 min.
moderate
The above stated information is true and accurate to the best of your knowledge.
Signature:
Date:
Reviewed By:
Date:
Office Use Only
RBP:
CHOL:
Risk Level:
Initials:
Note: If the client does not have a current cholesterol profile, you must note diet, BMI and WHR for review.
low