Breakout Fitness

Health History Questionnaire and
 Nutritional programming information sheet

Name:

Date of Birth:

Age:

Address:

City, State, Zip:

Home Phone:

Work Phone:

Employer:

Occupation:

Email address:

In case of emergency, please notify:

Name:

Relationship:

Address:

City, State, Zip:

Home Phone:

Work Phone:

Physician:

Phone:

Are you under the care of a physician, chiropractor, or other health care professional for any reason?

If yes, list reason:

Are you taking any medications? (If yes, complete the following)

Type, Dosage/Frequency, Reason for Taking:

 Please list any allergies:

Has your doctor ever said your blood pressure was too high?

Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?

Are you over the age of 65?

Are you unaccustomed to vigorous exercise?

FAMILY AND PERSONAL MEDICAL HISTORY

Is there a family history for any condition listed below?   If you are personally experiencing any of these conditions, fill in the pertinent information:

Asthma:

Respiratory/Pulmonary  Conditions:

Diabetes: Type I:            Type II:                      How Long?

Epilepsy: Petite Mal:                             Grand Mal:                         Other: Osteoporosis:

Heart Disease:   

LIST THE DIAGNOSIS AND EXAMINING PHYSICIAN: 

LIFESTYLE AND DIETARY FACTORS

Please fill in the information below or check the pertinent boxes:

Occupational Stress Level:            Low                     Medium                    High 

Energy Level:      Low          Medium                  High

Caffeine Intake/Daily:                          List type of caffeinated drink: 

Alcohol Intake/Weekly:                        List type of alcoholic drink:

Colds Per Year:                  

Anemia:

Gastrointestinal Disorder:

Hypoglycemia:

Thyroid Disorder:

Pre/Postnatal:

CARDIOVASCULAR

Please check the pertinent boxes below if the answer is yes:

High Blood Pressure:

Hypertension:

High Cholesterol:

Hyperlipidemia:

Heart Disease:

Heart Disease:

Heart Attack:

Stroke:

Angina:

Gout:

Is there any reason not mentioned why you should not follow a regular exercise program?

If yes, please explain:

Have you recently experienced any chest pain associated with either exercise or stress?

If yes, please explain:

SMOKING

Please check the box that describes your current habits:

Non-user or former user:   Date quit:

Cigar and/or pipe 

15 or less cigarettes per day

16 to 25 cigarettes per day

26 to 35 cigarettes per day

More than 35 cigarettes per day

MUSCULOSKELETAL INFORMATION

Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort:

 Head/Neck:

 Upper Back:

 Shoulder/Clavicle:

 Arm/Elbow:

 Wrist/Hand:

 Lower Back:

 Hip/Pelvis:

 Thigh/Knee:

 Arthritis:

 Hernia:

 Surgeries:

 Other:

 NUTRITIONAL INFORMATION

Are you on any specific food/diet plan at this time?

If yes, please list:

Do you take dietary supplements?

If yes, please list:

Do you experience any frequent weight fluctuations?

Have you experienced a recent weight gain or loss?

If yes, list change:

Over how long?

How many beverages do you consume per day that contain caffeine?

How would you describe your current nutritional habits?

Other food/nutritional issues you want to include (food allergies, mealtimes, etc.)

  WORK AND EXERCISE HABITS

 Please check the box that best describes your work and exercise habits.

Intense occupational and recreational exertion

Moderate occupational and recreational exertion

Sedentary occupational and intense recreational exertion

Sedentary occupational and moderate recreational exertion

Sedentary occupational and light recreational exertion

Complete lack of all exertion

To what degree do you perceive your environment as stressful?

Work:  Minimal                   Moderate             Average                 Extremely

Home:  Minimal                   Moderate               Average                 Extremely

Do you work more than 40 hours a week?

Please make any other comments you feel are pertinent to your exercise program.

NAME:

SIGNATURE: 

DATE:

SIGNATURE OF PARENT:

WITNESS or GUARDIAN (for participants under the age of majority)