General Information & History
Name:
Date:
E-Mail:
Phone:
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DOB:
1. Do you currently or have you ever experienced the following:
elevated blood pressure
elevated cholesterol
diagnosed heart disease
heart murmur or mitral valve prolapse
chest pain with exertion
diagnosed arrhythmia or irregular heartbeat
“light-headedness”, dizziness or fainting
blood clot / deep vein thrombosis / embolism
asthma – do you carry medication or a pump? Y /N
C.O.P.D. ( emphysema, chronic bronchitis, asthma )
epilepsy
allergies of any type – if yes please indicate:
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arthritis – if yes, which type & which joints are affected?
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osteoporosis or osteopenia – if yes, which areas are affected?
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diabetes – if yes, what type ? if insulin-dependent, where/how do you carry your
medication? ___________________________________________________________________________
any complications from diabetes? If yes please list:
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reflux, chronic heartburn or ulcer
inflammatory bowel disease ( ulcerative colitis, Crohn’s disease )
 hepatitis or other liver disease
 hernia – if yes, what type & if surgery?
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 any musculo-skeletal injuries – sprains, strains or fractures?
If yes, please list what/when:
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 any falls, car or other traumatic accidents?
If yes, please list what/when:
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 have you had a concussion or concussions? If yes, please list when:
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 any other medical condition not listed above?
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 any other surgeries or medical procedures? if yes, what & when:
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do you have a pacemaker?
do you have sleep apnea?
do you wear corrective lenses /glasses?
do you wear orthotics or a brace of any kind?
has a physician or dietician told you to lose weight?
have you ever consulted a physiotherapist?
do you live with any level of pain – if yes, please describe:
if applicable, please list the medications and supplements you are currently taking:
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do you use non-prescription painkillers on a regular basis? if yes please indicate
for what purpose:
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how many hours of “screen time” on average do you spend per day? __________
what specific postures or actions are you or were you engaged in at work – constant
sitting or standing, sustained forward bending, twisting, lifting, reaching?
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have you had a work-related injury or injuries? If so, please describe:
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Form reference: Baillargeon, J., Malone, L. YM-YWHA Therapeutic Fitness Program. Montreal 2012