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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
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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Client Print Name
*
Date
*
Parent/Guardian Signature
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Parent Guardian Print Name
Date
Submit
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