Medical History Form

Please fill out the information below - all of your answers are confidential, and will be used only to ensure the quality of your fitness program.

If you haven't already, please download the consent form, as well as the policies form (for those registering for the Mom's class, download this version of the policies form).

Name * First Last
Address *

Street Address

Address Line 2

City

State

Zip Code
Email *

Phone Number * - (###) - ### ####
Date of Birth * / MM / DD YYYY

Height and Weight * Height Weight
Emergency Contact *

Emergency Contact Phone Number * - (###) - ### ####
Physician's Name * Full Name
Physician's Address *

Street Address

Address Line 2

City

State

Zip Code
Physician's Phone Number * - (###) - ### ####

Date of Your Last Exam / MM YYYY
Are you currently under a doctor's care? Yes No
If yes, please explain why:
Medical History
Have you ever been diagnosed with heart problems? Yes No
Do you have excessive trouble breathing during times of exertion? Yes No
Do you ever have pains in your heart and chest? Yes No
Has a doctor ever said your blood pressure was too high? Yes No
Do you smoke? If no, did you ever smoke? Yes No
Do you have diabetes mellitus? Yes No
Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise or might be made worse with exercise? Yes No
Have you a history of any condition, e.g. hernia, that may be aggravated by lifting weights? Yes No
Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to? Yes No
Are you over age 65 and not accustomed to vigorous exercise? Yes No
Are you pregnant? Yes No
If you are pregnant, have you received medical clearance for increased physical activity? Yes No
Are you on any medications? Yes No
If yes, please list:
List any injuries, past or present, or limiations that may affect your exercise program. (e.g. low back pain, cartilage tear, broken collarbone, etc.)
If you answered yes to any of the questions listed above, you may be required to get your physician's written approval before starting.
Do you like to exercise? Yes No
Are you currently exercising? Yes No
If yes, what physical activities are you doing? How often?
Have you ever exercised regularly? Yes No
If yes, list your reasons for stopping.
Are your family/friends/co-workers willing to exercise with you? Yes No
Do they encourage you to exercise? Yes No
Are they willing to rearrange their schedules to accommodate your exercise time? Yes No
Are there opportunities during your work day when you might use 20-30 minutes for physical activity? Yes No
Have you ever attended a group exercise class? Yes No
If yes, what type of class/es? How many per week? For how long?
What are your short term and long term fitness goals?
Have you ever used a personal trainer? Yes No
If yes, when? Where? How long?
List your reasons for stopping:
Do you have access to exercise equipment in your home? Yes No
If yes, what type of equipment do you have and do you use the equipment?
If no, would you like to purchase equipment? Yes No
Please comment on anything that you feel will help me design your exercise program or help me create a more comfortable exercise environment for you.