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10311 NE 141st St Kirkland, WA 98034
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Health Questionnaire
AGREEMENT FOR SERVICES FROM DESTINY MANAGEMENT
Step 1 of 6
16%
This agreement is made on
*
Date Format: 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Business Phone
Email
Birthdate
Date Format: MM slash DD slash YYYY
Age
Employers Name
Height - ft/in
Weight (lbs)
Date of Last Physical Exam
Date Format: MM slash DD slash YYYY
Personal Physician
Phone
Goals
Limitations
How 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 Management
General History
Do 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 Specify
Family 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 History
Do 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 History
Do 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 Specify
Medications
Are you currently taking any medications?
Medication
Condition
Over the Counter Supplements
Medication
Condition
Nutritional History
Average number of caffeine drinks per day
Average number of alcoholic drinks per day
Are you presently dieting?
Yes
No
What kind of diet?
Have you participated in structured diet plans in the past?
Yes
No
Please List
Name of Diet
Dates
Weight Lost
How Long Maintained Weight Loss?
Nutritional History
What 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/Neck
Shoulder/Clavicle
Arm/Elbow
Wrist/Hand
Back
Hip/Pelvis
Thigh/Knee
Lower Leg/Ankle/Foot
Do you have chronic, or recurrent pain in any part of your body?
Yes
No
Describe
What 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
Where
Have you ever been diagnosed with osteoporosis?
Yes
No
Are you currently undergoing physical therapy?
Yes
No
Women’s Health
Are 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 History
Have 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)
Lifestyle
Is 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 Contact
Phone
Relationship
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.
Signature
Guardian Signature(if under 18 years of age)
Date
Date Format: MM slash DD slash YYYY
Reviewed By
INFORMED CONSENT FOR A HEALTH RELATED EXERCISE TEST
1. Explanaon 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 compositions test which is analyzed by taking several skinfold measures to calculate the percentage of body fat along with 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 me because of signs of fague 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
Informaon 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
*
Date Format: MM slash DD slash YYYY
Signature
*
