Health Screening Form printable pdf download

HEALTH SCREENING FORM

Name _____________________________________________ Date _______________________

Sex ______ Age _____ Height__________ Weight__________ Phone _____________________

What is the present state of your general health? _______________________________________

Physician’s Name ________________________________________ Phone _________________

Emergency Contact _______________________________________ Phone _________________

What medications are you presently taking? including vitamins, herbals, nutritional

supplements________________________________________________________________________________________

__________________________________________________________

Are you now or have you been pregnant within the past three months? _____________________

Has your physician restricted your participation in exercise? ________If yes, please describe

______________________________________________________________________________

Do you have now or have you ever had:

Yes / No

1. A history of heart problems? _____ If yes, please explain: ____________________________

____________________________________________________________________________

2. A history of lung disease? _____ If yes, please explain: _____________________________

____________________________________________________________________________

3. Chest, neck, and/or jaw pains/discomforts at rest or during exertion? _____

4. Difficulty with physical exercise, such as chest pain/discomfort,

dizziness or extreme shortness of breath? _____

5. Muscle, joint, or back disorder that could be aggravated by

physical activity? _____ If yes, please explain:_____________________________________

___________________________________________________________________________

6. A chronic illness? _____ If yes, please list: ________________________________________

___________________________________________________________________________

7. High blood pressure? _____

8. Diabetes? _____ Insulin Dependant?_______

9. Cigarette-smoking habit? _____ If yes, how many packs per day?______

10. High blood cholesterol? _____

11. History of heart problems in a 1

degree relative

( parent, siblings, children)? _____

If yes, at what age?

Health Screening Form