Exercise Science Employee Fitness Center

Kinesiology, Sport Studies and Physical Education

Health History Questionnaire

The College at Brockport – Exercise Science Employee Fitness Program

I.PERSONAL DATA:

Name ______

Age _____ Birth Date:______Gender _____

Address ______

City ______

State______Zip ______

Phone: Home (_____)______Cell (____)______

E-Mail______

Occupation ______

In case of emergency during testing, contact:Name ______

Relation______

Phone ______

II.MEDICAL - SURGICAL HISTORY:

Check (√) if answer is yes. Have you ever had (if so, indicate date):

DateDate

( ) Rheumatic heart disease______( ) Accidents______

( ) Heart Murmur______( ) Chest pains______

( ) High Blood Pressure______( ) Tightness in chest______

( ) Gout ______particularly during exercise

( ) Varicose Veins______( ) Shortness of breath______

( ) Lung Disease______( ) Heart palpitations______

( ) Injuries to back______( ) Excessive cough______

( ) Epilepsy______( ) Stroke______

( ) Diabetes______( ) Heart Attack ______

( ) Heart Surgery______( ) Difficulty sleeping______

( ) Other Operations______( ) Fatigue______

( ) Kidney Disease______( ) Calf pain or cramps______

( ) Stomach Ulcers ______with exercise

( ) Arthritis______( ) Nervousness______

( ) Hospitalizations______( ) High Cholesterol______

( ) Cardiac Catheterization______( ) other problems______

Please explain any checked answers and describe any illnesses, surgeries or diseases not listed above:

______

______

______

III.MEDICATIONS:

Please list medications that you are presently taking.

Drug Dose Reason for taking

______

______

______

______

IV.PRESENT HEALTH

What do you consider your present overall state of health to be?______

If your overall health is not good what is your major complaint or problem and when did the symptoms begin?______

______

______

Have you ever sprained, strained, severely bruised, dislocated, broken, or had chronic pain to any of the following bones or joints? (please circle all that apply)

JawNeckShoulderElbowWrist

BackHipKneeAnkleFoot

Shin/calfThighArmOther:______

Explain all circled answers:______

______

______

______

______

______

Do you smoke? Yes ______No______If yes, ______per day for

______years.

Do you follow a special diet? If yes, please describe______

______

Do you drink alcoholic beverages? If yes, ______per week.

V.FAMILY MEDICAL HISTORY:

To your knowledge, have any of your relatives had any of the following?:

YesNoRelative (Who?)

Cancer ______

Diabetes______

Heart Disease______

High blood pressure______

High Cholesterol ______

Stroke______

Peripheral vascular disease______

VI.CURRENT EXERCISE REGIMEN:

Briefly describe any regular cardiovascular/aerobic exercise that you participate in:

Type of exerciseNumber of times/weekNumber of minutes/session

______

______

______

Do you use machines (e.g., Nautilus, Cybex) or free weights? (Please circle one or both)

Briefly describe any regular resistance training (weight lifting) that you participate in:

______

______

______

VII.GOALS FOR HEALTH AND FITNESS:

Please indicate what your health and fitness related goals are. Be as specific as possible. For example: 1) lower my cholesterol by 20 points, 2) Lose 15 pounds in 4 months, and 3) run a 5km race in less than 30 minutes.

______

______

______

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