Health History Form
Name________________________
Date_________________
Date of Birth_________________
Age___________ Sex_________
Home Phone_________________
Work Phone_________________
Physician’s Name___________________ Phone__________________
Are you currently participating in any form of exercise?
Height_________
□ Yes □ No
Weight_________
PERSONAL MEDICAL HISTORY: Please check if apply
1.
Have you had a heart operation?
 Yes
When & What Type__________________________
 No
2.
Have you been diagnosed or treated by a physician for:
 Acquired Immune Deficiency Syndrome
 Arthritis: Type____________________________
 Cancer: Type_______________________________
 Chronic Obstructive Pulmonary Disease
 Diabetes: Type______________________________
 Emphysema
 End-Stage Renal Disease
 Epilepsy
 Heart Problem: Type____________________________
 Hepatitis: Type_________________________________
 Muscle or Nerve Problem: Type____________________
 Recent Surgery: Type______________________________
 Stroke
 Other
Comments:___________________________________________________
RISK FACTORS: Please check if apply
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Male over the age of 45
Female over the age of 55 or premature menopause without estrogen
replacement therapy
Family History of heart disease
Currently a smoker
High/Low blood pressure (circle one) or currently taking blood
pressure medication
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Total serum cholesterol >200mg/dl or HDL <35mg/dl
Insulin dependent diabetes mellitus (IDDM) and >30 years of age or
have had IDDM for >15 years
Non-insulin dependent diabetes mellitus (NIDDM) who is >35 years of
age
Sedentary lifestyle with little or no physical activity
CURRENT SYMPTOMS
Please check the symptoms you are currently experiencing if any.
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Pain or discomfort in the chest, neck, jaw, or arms with exercise
Shortness of breath at rest or with mild exertion
Dizziness
Labored breathing at night
Swelling of ankles
Frequent heart palpations or fluttering
Unusual fatigue or shortness of breath with usual activities
Known heart murmur
If you checked any current symptoms, please explain:
MEDICATIONS; Please check the medication you are currently taking.
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Heart…………………____________________________________
Blood Pressure………_____________________________________
Anti-depressants……._____________________________________
Thyroid………………____________________________________
Aspirin……………….____________________________________
Other…………………_____________________________________
I HEREBY CLAIM THAT THE ABOVE INFORMATION IS TRUE. I WILL
NOTIFY MISSISSIPPI COLLEGE IN WRITING IF ANY OF THE ABOVE
INFORMATION SHOULD CHANGE.
SIGNATURE___________________________________ DATE______________