Health Questionnaire Health Questionnaire Health & Fitness History Step 1 of 6 16% This agreement is made on* MM slash DD slash YYYY For most people, physical activity should not pose any problem or hazard. This questionnaire has been designed to identify those people for whom physical activity might be inappropriate, or those who should have medical advice concerning the type of activity most suitable for them. If you answer “yes” to any of the questions below, consult with your doctor before starting any exercise program.Name*Last Name*Gender Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneBusiness PhoneEmail Birthdate MM slash DD slash YYYY AgeEmployers NameHeight - ft/inWeight (lbs)Date of Last Physical Exam MM slash DD slash YYYY Personal PhysicianPhoneGoalsLimitationsHow many days per week can you commit to a resistance program?How may days per week can you commit to a cardiovascular program?What is the total amount of time per day you can commit to an exercise program?(in minutes)How can we best assist you with a nutrition program?How did you hear of Destiny ManagementGeneral HistoryDo you currently have an illness or infection? Yes No Please Specify:Has your physician ever told you that: your cholesterol was too high? Yes No Do you have history of high blood pressure? Yes No Have you been diagnosed with diabetes? Yes No Are you taking medication? Oral Injection What kind of diabetes? Type I Type II General History, cont.Do you have a history of the following conditions? Allergies Infectious mononucleosis Anemia Multiple sclerosis Epilepsy or other seizures Liver disorder Gallbladder problems HIV positive Renal disorder Other Please SpecifyFamily History (Immediate family only)>Heart Attacks No Yes If Yes Age > 50 Age < 50 High Blood Pressure No Yes If Yes Age > 50 Age < 50 High Cholesterol No Yes If Yes Age > 50 Age < 50 Stroke No Yes If Yes Age > 50 Age < 50 Angina (Chest Pain) No Yes If Yes Age > 50 Age < 50 Diabetes No Yes If Yes Age > 50 Age < 50 Congenital Heart Disease No Yes If Yes Age > 50 Age < 50 Aneurysms No Yes If Yes Age > 50 Age < 50 Heart Operations No Yes If Yes Age > 50 Age < 50 Asthma/Hay Fever No Yes If Yes Age > 50 Age < 50 Obesity No Yes If Yes Age > 50 Age < 50 Osteoporosis No Yes If Yes Age > 50 Age < 50 Cancer No Yes If Yes Age > 50 Age < 50 Smoking HistoryDo you currently smoke? No Yes For how many years?Number of cigarettes, cigars and/or pipe bowls smoked per day?If you are an ex-smoker, when did you stop? Pulmonary HistoryDo you experience breathlessness after mild exercise? Yes No Have you ever experienced any of the following:Asthma? Yes No When?Bronchitis? Yes No When?Emphysema? Yes No When?Pneumonia? Yes No When?Lung Disease? Yes No When?Other? Please SpecifyMedicationsAre you currently taking any medications?MedicationCondition Over the Counter SupplementsMedicationCondition Nutritional HistoryAverage number of caffeine drinks per dayAverage number of alcoholic drinks per dayAre you presently dieting? Yes No What kind of diet?Have you participated in structured diet plans in the past? Yes No Please ListName of DietDatesWeight LostHow Long Maintained Weight Loss? Nutritional HistoryWhat was your heaviest weight?(lbs)What was your weight one year ago?(lbs)What was your weight at age 21?(lbs)What do you consider a healthy weight for yourself? (lbs)How would you describe your nutritional habits? Excelent Good Fair Poor Have you ever had an eating disorder? Yes No What and When?What Foods do you usually snack on?How many meals do you eat per day?Orthopedic History Describe any present or past musculoskeletal or joint conditions you have (i.e muscle pulls, sprains, fractures, surgery, pain, arthritis, or any other general discomfort):Head/NeckShoulder/ClavicleArm/ElbowWrist/HandBackHip/PelvisThigh/KneeLower Leg/Ankle/FootDo you have chronic, or recurrent pain in any part of your body? Yes No DescribeWhat relieves the pain?Do you avoid activity because of the pain? Yes No Do you have weakness in any particular part of the body? Yes No WhereHave you ever been diagnosed with osteoporosis/osteopenia? Yes No Are you currently undergoing physical therapy? Yes No Women’s HealthAre you currently pregnant? Yes No Have you given birth in the last eight weeks? Yes No Are you currently taking birth control pills? Yes No Are you currently breast feeding? Yes No Cardiovascular HistoryHave you ever had any of the following:(check all that applies) Heart attack or stroke Cardiac or vascular surgery or congestive heart failure Cardiomyopathy (heart enlargement) Abnormal resting or exercise EKG Coronary artery disease Rheumatic fever Phlebitis Do you have a history of any of the following:(check all that applies) Angina (chest pain) Palpitations or tachycardia Badly swollen feet or ankles Severe dizziness or fainting Heart murmur Claudication (pain in the legs) LifestyleIs your occupation: Sedentary Moderately active Active Heavy labor How stressful is your occupation? Minimal Moderate Average Extreme How would you characterize your overall stress level? High Medium Low Average number of hours you sleep per night?Emergency ContactPhoneRelationship I understand the nature and purpose of the Physical Activity Readiness Questionnaire and am aware that any strenuous physical activity involves risks. Accordingly, I release, discharge, absolve, and hold harmless Destiny Management, their agents, instructors and employees, for any and all liability arising from any accident, injury, or loss sustained by me as a result of activities at or present in the Facility. I declare to the best of my knowledge my answers are true, correct, and complete.SignatureGuardian Signature(if under 18 years of age)Date MM slash DD slash YYYY Reviewed ByINFORMED CONSENT FOR A HEALTH RELATED EXERCISE TEST 1. Explanation of the Exercise Test You will perform a battery of fitness tests that may include a cardiovascular test on a cycle ergometer or a bench step test, a sit & reach test for flexibility, a push‐up test and a sit‐up test for muscular endurance, and a body composition test which is analyzed by taking several skinfold measures to calculate the percentage of body fat and/or circumference measurements. For the cardiovascular test, the exercise intensity will begin at a level you can easily maintain and will be advanced in stages depending on your fitness level. For the other tests, you will be going to failure. We may stop the tests at any time because of signs of fatigue or you may stop when you wish because of personal feelings of fatigue or discomfort. 2. Risks and Discomforts There exists the possibility of certain changes occurring during the tests. They include abnormal blood pressure, fainting, disorder of heart beat, and, in rare instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by evaluation of preliminary information relating to your health and fitness and by observations during the tests. Emergency equipment and trained personnel are available to deal with unusual situations that may arise. 3. Responsibilibies of the Parcicipant Information you possess about your health status or previous experiences of unusual feelings with physical effort may affect the safety and value of your exercise tests. Your prompt reporting of feelings with effort during the exercise tests itself are also of great importance. You are responsible to fully disclose such information when requested by the testing staff. 4. Benefits to be Expected The results obtained from the exercise tests may assist in diagnosis of your illness or in evaluating what type of physical activities you might do with low risk of harm. 5. Inquiries Any questions about the procedures used in the exercise tests or in the estimation of functional capacity are encouraged. If you have any doubts or questions, please ask us for further explanations. 7. Freedom of Consent Your permission to perform these exercise tests are voluntary. You are free to deny consent or stop the test at any point if you so desire. I have read this form and I understand the test procedures that I will perform. I consent to participate in the tests.Date* MM slash DD slash YYYY Signature* 77488
