Biokinetics, Kinesiology & CSCS
5002 51st Street, Cold Lake, Alberta T9M1X2
Tel: (780) 201-0133
Cel: (780) 201-5556
Email: brendenbartonbio@gmail.com
Pre-Appointment Health Screening Questionnaire
Personal Contact Details
Full name and Surname: _________________________________________________________
Address: _____________________________________________________________________
City: _____________________________________
Province:__________________________________
Postal Code: ________________________
Phone (Home): ______________________ (Work): ___________________________________
(Mobile): __________________________
Email: _______________________________________________________________________
Date of Birth: _______________________
Age: __________
Occupation: ___________________________________________________________________
Emergency Contact Person: _______________________________ Phone: _________________
Family Doctor: _________________________________________ Phone: _________________
Physiotherapist (if required) _______________________________ Phone: _________________
Other therapist (if required) _______________________________ Phone: _________________
Reason for Appointment (in your own words):
______________________________________________________________________________
______________________________________________________________________________
Orthopedic Conditions
Sports Performance
Youth Athletic Development
Health Promotion
Biokinetics, Kinesiology & CSCS
5002 51st Street, Cold Lake, Alberta T9M1X2
Tel: (780) 201-0133
Cel: (780) 201-5556
Email: brendenbartonbio@gmail.com
Pre-Screening Health History

















Has your doctor ever told you that you have cardiovascular/heart disease? Yes/No
Do you have a family history of cardiovascular/heart disease, stroke, elevated cholesterol
levels or sudden death before the age of 65? Yes/No
Are you diabetic? Yes/No
If yes, do you use medication Yes/No If yes, type?
_______________________________________________________________________
Have you ever had a stroke (including mini strokes)? Yes/No
Are you asthmatic? Yes/No If yes please
elaborate:________________________________________________________________
Are you taking any asthma medication? Yes/No Type:____________________________
Has your doctor ever told you that you have hypertension? Yes/No
If yes when was it last checked and what was the reading? Date: ____________________
Reading: Systolic______ Diastolic______
Medication:
________________________________________________________________________
________________________________________________________________________
Stress levels (0 – 5) ___________
Are you pregnant or trying to get pregnant? Yes/No
Are you using any form of prescribed medication at present? Yes/No
________________________________________________________________________
________________________________________________________________________
Are you using any non-prescription drugs, including, street drugs or performance
enhancers? Yes/No
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you ever been advised by your doctor not to exercise? Yes/No
Have you ever had any pain or palpitations in the chest, heart or surrounding areas,
especially during exercise? Yes/No
Do you ever feel faint or dizziness during exercise? Yes/No
Do you experience unusual fatigue or shortness of breath at rest or during mild exercise?
Yes/No
Do you have a pacemaker? Yes/No
Have you ever been awakened at night by an attack of shortness of breath or had an
attack of shortness of breath after exercise? Yes/No
Orthopedic Conditions
Sports Performance
Youth Athletic Development
Health Promotion
Biokinetics, Kinesiology & CSCS
5002 51st Street, Cold Lake, Alberta T9M1X2
Tel: (780) 201-0133
Cel: (780) 201-5556
Email: brendenbartonbio@gmail.com



Do you ever get pain in your calves or lower legs that is not due to stiffness or soreness?
Yes/No
Have you been hospitalized recently? Yes/No Date: ______________________
Operation within the last 12 months? Yes/No Date: ______________________
Pre-Screening Health History (cont.)





Do you smoke cigarettes? Yes/No
How many per week? __________
Alcohol Consumption? Yes/No How much? _____________________
Do you drink coffee/caffeinated products? Yes/No
How much per day (Cups)? ___________________________________
Are you currently dieting or fasting? Yes/No
Do you have any of the following: (tick)
o
o
o
o
o
Gout
Osteoarthritis
Rheumatoid Arthritis
Fibromalagia
Osteoporosis
Injury History
Dominant Hand ___________ Leg___________
Have you ever had injury, surgery to your (if yes, please elaborate):
o Ankles:_________________________________________________________________
o Knee:__________________________________________________________________
o Hip/Pelvis:______________________________________________________________
o Shoulder:_______________________________________________________________
o Neck:__________________________________________________________________
o Back/Spinal injury:______________________________________________________
Orthopedic Conditions
Sports Performance
Youth Athletic Development
Health Promotion
Biokinetics, Kinesiology & CSCS
5002 51st Street, Cold Lake, Alberta T9M1X2
Tel: (780) 201-0133
Cel: (780) 201-5556
Email: brendenbartonbio@gmail.com
o Elbow:_________________________________________________________________
o Wrist:__________________________________________________________________
o Other:__________________________________________________________________
Exercise History
What are your activity patterns (including gardening, housework etc?)
Frequency: ________ exercise sessions per week.
Intensity: Sedentary
Duration:_______ minutes/session
Moderate
Vigorous
Do you play a sport? ____________________________________________________________
Level: _______________________________________________________________________
Thank you for completing the screening. Your complete and thoughtful answers enable us to
develop safe, effective rehabilitation/conditioning protocols, ensuring that the outcomes are
achieved as efficiently as possible.
I, the undersigned, confirm that I have answered all questions truthfully and to the best of my
knowledge.
Name: _____________________________________ Signature: ________________________
Date: _____________________
Orthopedic Conditions
Sports Performance
Youth Athletic Development
Health Promotion