Health History Questionnaire


Please complete each question as accurately as possible. 
All personal information is confidential.  Explain in detail where needed. 
Thank you.
   
*Items marked with a red asterisk must be filled out in order to submit your form.
 

*First Name:

Emergency Contact

*Last Name:

*First Name:

*Street:

*Last Name:

*City:

*Tel:

*State: *Zip Code:

*Preferred Hospital:

*Age:    *DOB:

Parent/Guardian (if athlete under 18 yrs.)

*Sex: Female Male

First Name:

*Primary Tel: no dashes

Last Name:

Cell Tel:

Tel:

Work Tel:

Academics/Career

*Email:

School:

Sport(s):

Grade:

Position(s):

GPA:

Sports Level:

Occupation:

*Dominant Hand: Right  Left

*Rate Your Stress Level (1 to10):

*Are You Presently Exercising: Yes  No

If so, what type of exercise are you doing:

Important information your trainer should know to help you achieve your goals;

Medical History & Present Medical Condition

*Have you ever had any illnesses, hospitalizations, or procedures in the past two (2) years?
No  Yes IF YOU CHECKED YES, YOU MUST EXPLAIN BELOW

If yes, explain:

   

Check any Conditions or diseases you have or had in the past:

Heart attack, coronary bypass or other cardiac surgery

Extra, skipped, or rapid heartbeats or palpitations

Diabetes

Cold hands or feet

Stroke

Unusual or shortness of breath

Peripheral vascular disease

Light-headedness or fainting

Phlebitis or emboli

Epilepsy or seizures

Rheumatic fever

Anemia

High blood pressure

Asthma

Low blood pressure

Emphysema

Chest discomfort

Bronchitis

Heart murmur

Pneumonia

Ankle swelling

A chronic recurrent cough

Trouble sleeping

Anxiety or depression

Migraine or recurrent headaches

Emotional disorders

Swollen, stiff, or painful joints

Fatigue or lack of energy

Foot problems

Ulcers

Hip problems

Knee problems

Back problems

Stomach or intestinal problems

Shoulder problems

Hernia

Neck problems

Limited range of motion in joints

Broken bones

Arthritis
Bursitis

Chronic Fatigue, ADD
Problems with menstruation

Pregnant
 

1. Please explain in detail any of the above:

2. Please list any prescribed medications you are taking:

3.Please list any over-the-counter supplements you are taking:

4.Please list any allergies:

5.Please list date of last physical examination and results:

Other comments concerning your health?

 
Fitness & Health Goals

Improve Strength

Improve Flexibility

Cardiovascular Fitness

Lose Weight

Gain weight/muscle

Increase Energy

Reduce Stress

Injury Prevention

Stop Smoking/Drinking

Improve muscle tone

Improve Sports Performance

 
   

Other goals:

   

I do hereby state that I have to the best of my knowledge and belief, given the correct and accurate medical history report.

*Client Name:

Parent/Guardian:
 



Address:
Infinity Institute
19 W Passaic St.
Rochelle Park, NJ 07662

Phone:
Rehab: 201.845.8002
Fitness: 201.845.8022
Fax: 201.845.8088

Office Hours:
Open Daily AM & PM
Weekends by Appointment Only
   
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