Dominion Fitness


Dominion Fitness Health and History Questionaire
Name (first, last)
Date of Birth
Sex: Male Female
Weight
Height
Health History- Do you now, or have you had in the past 5 years:
History of heart problems, chest pain or stroke. YES NO
Increased Blood Pressure YES NO
Any chronic illness or condition YES NO
Difficulty with physical exercise YES NO
Advice from physician not to exercise YES NO
Recent Surgery YES NO
Pregnancy (now or within last 3 months) YES NO
History of breathing or lung problems YES NO
Muscle, joint, or back disorder, or any previous injury still affecting you YES NO
Diabetes or thyroid condition. YES NO
Cigarette smoking habit. YES NO
If Yes to previous question, how many packs per day
Obesity (more than 20% over ideal body weight). YES NO
Increased blood cholesterol YES NO
History of heart problems in immediate family YES NO
Hernia or any condition that may be aggravated by lifting weights YES NO
Rapid or runaway heartbeat YES NO
Skipped heartbeat YES NO
Rheumatic fever YES NO
Has your doctor ever said your blood pressure was too high? YES NO
Shortness of breath w/ or w/o exercise YES NO
Phlebitis or embolism YES NO
Stroke YES NO
Do you frequently have pains in your heart and chest? YES NO
Has your physician ever said you have heart trouble? YES NO
Do you often feel faint or have spells of severe dizziness? YES NO
Are you over age 65 and not accustomed to vigorous exercise? YES NO
Are you unaccustomed to vigorous exercise? YES NO
Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise? YES NO
Recent hospitalization for any cause. YES NO
If yes answer to previous question, please list specifics:
Orthopedic History- have you experienced any problems, either exercise or non-excercise related, with:
Head or Neck? YES NO
Shoulders or rotator cuffs? YES NO
Arms, Elbows,Wrist or Hands? YES NO
Back? YES NO
Hip or Pelvis? YES NO
Knees, ankles or feet? YES NO
Are you taking any medications or drugs? YES YES
If yes to previous question, what type?
Describe your exercise program now.
Describe your daily food consumption for a typical day:(Morning, Noon, Night, Snacks)
What types of exercise interest you? Please select all that apply. Walking Jogging Swimming Cycling Dance Exercise Strength Training Stationary Biking Racquetball Tennis
What are your goals? Please be specific.
Please indicate best time for you to be reached by phone. Call may take approximately 15 minutes. Hours : Minutes
Phone Number (We will contact you if additional information is needed)
Email Address
How did you hear about us? Select all that apply. Web search (google, yahoo....other) Flyer/mailer Craigslist Facebook,Twitter Dr. Referral Radio ad Are you a former client? Mobile Vehicle Friend referral