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info@EliteFitandMobility.com 706-424-0528

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Medical History Form

Client First Name*

Client Last Name*

Relationship to Client*

Self

Parent/Guardian

Parent/Guardian Name

Email*

Phone*

Address*

Client Date of Birth*

Month

Day

Year

Age*

Weight*

Height*

Sex*

Male

Female

Emergency Contact Name & Phone #*

Physician Name & Speciality*

Physician Phone #*

Physician Address*

Are you currently under a physician's care?*

yes

no

If yes, explain:

Date of last physical examination:*

Have you ever had an exercise stress test:*

yes

no

not sure

If yes, results were:

normal

abnormal

Do you take any medication on a regular basis?*

yes

no

If yes, list medications and reasons:

Have you been hospitalized?*

yes

no

If yes, date and reason:

Do you smoke?*

yes

no

Are you pregnant?*

yes

no

n/a

Do you drink alcohol more than 3 times a week?*

yes

no

Rate your stress level*

No Stress

Low Stress

Moderate Stress

High Stress

Very High Stress

Are you moderately active on most days of the week?*

yes

no

Check all that apply.*

none

asthma

back pain (explain)

chest pain with exertion

cramping pains in legs or feet

diabetes

emphysema

epilepsy

heart attack

heart disease

heart murmur

high blood pressure

high cholesterol

irregular heart beat/palpitations

joint pain (explain)

lightheadedness/fainting

metabolic disorder (thyroid, kidney, etc)

muscle pain or injury (explain)

stroke

unusual shortness of breath

other

Explanation*

To the best of my knowledge, the above information is true.

Client Signature*

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Signature field is empty.

Client Print Name*

Date *

Parent/Guardian Signature

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Signature field is empty.

Parent Guardian Print Name

Date

info@EliteFitandMobility.com

706-424-0528

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