Health History Questionnaire printable pdf download

Health History Questionnaire

Form 5-1

Permission to reproduce this form has been granted to IFPA certified personal trainers only.

Health History Questionnaire

Please fill this form out with complete accuracy – it is essential for your safety.

Name:__________________________

Age:_____

Sex______

Height:______ Weight:______

Address:________________________

Work Phone:______________

Home Phone:_____________

________________________________

Occupation:_________________________________________

Known Diagnosis, if any ______________________________________________________________________

Do you have or have you ever had:

YES

Have you ever been hospitalized

Heart Attack or Heart Trouble

Chest Pain or Angina Pectoris

Coronary Bypass or Angioplasty

Abnormal or Positive Exercise Stress Test

Heart Murmur – Noted by a Physician to be

significant or suggestive of a heart abnormality

Irregular Heart Beat or Rhythm – Noted by a

physician to be significant or suggestive of a heart

abnormality

High Blood Pressure Above 145/95

Impaired Circulation

Stroke

Convulsions or Loss of Consciousness

Diabetes Mellitus

High Blood Cholesterol Level

Are You Pregnant

Do you smoke or have you ever smoked or used

smokeless tobacco for a total of 10 years

Health History Questionnaire