health history web form

Health History Form

THANK YOU FOR TAKING TIME TO COMPLETE THIS FORM

Please answer each question carefully and completely. This is very important information and will contribute significantly to the development and implementation of your personal health and fitness program. We want you to be successful, and want to truly understand the demands you face each day. If you have any questions, please submit at the end of the questionnaire.

PART I PERSONAL INFORMATION

Name

Birth Date

Parent/Guardian

Address

City

Phone (Home)

Phone (cell)

Phone (work)

Email

Phone (Parent/Guardian)

Email (Parent/Guardian)

Emergency Contact

Emergency Contact Phone

PART II MEDICAL HISTORY

A. PRE EXISTING CONDITIONS

Do you currently have, or have you in the past had complications with any of the following (Check all that apply):

Please elaborate on any checked above, including any chronic illness or disease

Has an immediate family member (parent/sibling) had a heart attack, stroke or cardiovascular disease before the age of 55?

Yes No

Has your physician ever advised you against exercise?

Yes No

If Yes when and why

Has your physician ever said you have heart troubles?

Yes No

Do you smoke or have you quit in the last 6 months?

Yes No

Do you consume alcohol on a regular basis?

Yes No

If yes, approximately how much?

Are you currently pregnant?

Yes No

If you have been pregnant, please include dates & any related health issues; c-section...

B. Health Care & Medications

Please list all medical care providers, the reasons for seeing them, and any contact information.

Health Care Provider 1

Reason for seeing them

Contact info

Health Care Provider 2

Reason for seeing them

Contact info

Health Care Provider 3

Reason for seeing them

Contact info

Health Care Provider 4

Reason for seeing them

Contact info

Health Care Provider 5

Reason for seeing them

Contact info

Would you like me to contact any of the above practitioners before our meeting?

Yes No

Which provider?

Please list any medications taken on a regular basis and reasons for taking each:

Please list any dietary or nutritional supplements taken on a regular basis and reasons for taking each:

Please list any non-prescription drugs (marijuana, etc) taken on a regular basis and reasons for taking each:

Please list any medications, supplements, or drugs you took previously for 6 months or more, and why your intake has changed;

C. Daily Life

Have you consulted with a professional with respect to diet or exercise? Please describe recommendations:

If you are following a special diet or eating program, please describe below:

Do you have any frustration or questions regarding exercise and wellness strategies?

Do you have any conflicting advice or information you would like addressed? If yes, please describe:

Do you feel with each year you are getting:

Healthier No Change Unhealthier

Do you habitually consume over 3-4 cups of coffee/cans of soda per day?

Yes No

How would you describe the emotional climate/level of stress in the following situations:

Home? Scale: 1=very bad, 10=very good

Work/school? Scale: 1=very bad, 10=very good

Financial? Scale: 1=very bad, 10=very good

Relational? Scale: 1=very bad, 10=very good

Please elaborate on, or describe the nature of any stress, challenges, to help understand what you are facing each day:

Please describe your sleep (hours, quality, etc.)

Do you have fatigue during the day?

Yes No

What is your occupation?

What are your main occupational activities? (check all that apply):

Please summarize how many hours per day you are in above noted positions, and for how many years have you been at this job.

What are your main occupational demands emotionally? (check all that apply):

consistent high pressure boring non stimulating intermittent high & low pressure emotionally exhausting emotionally fulfilling neutral

Do you play a musical instrument?

What instrument and how many hours a week?

Please describe a typical day (I wake up at 6:00 am and drink 1 cup of coffee and drive to work, I sit at a desk for 5-6 hour

other extra notes

D. Trauma/Injury/Surgery History *EXTREMELY IMPORTANT SECTION!

This includes significant physical pains and injuries you have experienced, even ones you may consider minor, non-medically treated injuries or events. PLEASE NOTE: the younger you experienced injuries, the more effect they may have had, so please consider everything you can remember, including your age when each “trauma” occurred.

Do you wear orthodics?

Yes No

Please describe your shoe wear, and what you wear the most throughout the week:

Do you have, or have you in the past had any of the following complications, including any pain, injury, surgery, loss of function. Please include AGE OF INJURY FROM CHILDHOOD UNTIL RECENT and whether it affects you currently with a “C”.

Senses

eyes ears throat nose

Please elaborate on checked items; include AGE OF INJURY, which eye, ear is involved, and C if currently affects you:

Head/Jaw (injury, whiplash, concussion, surgery, etc.)

head neck jaw nose