Victoria Wellness Professionals

Health History Questionnaire

Please answer each question. Your answers are kept confidential.

Name ______________________________ Date of Birth ________________

Address ____________________________ E-Mail ______________________

Occupation ____________________ Physician _______________________

Home Phone No. ________________ Work Phone No. _________________

In Case of Emergency Please Notify:

Name _________________________ Relationship _____________________

Address _______________________ Phone No. _______________________

1. Are you under the care of a physician, chiropractor, or other health care professional for any reason? YES ____ NO____

If yes, list reason: ________________________________________________________

________________________________________________________________________

2. Are you taking any medications? YES ____ NO____

If yes, please list: type, dosage, frequency and reason for taking:

________________________________________________________________________

3. Please list any allergies:

________________________________________________________________________

NOTE: In order to assist you in the development of a rewarding physical fitness program, we need to have your honest and accurate responses.

Screening Questionnaire

1. Has a Dr. ever said you have heart trouble? Yes ____ No ____

2. Have you ever had angina pectoris or sharp pain or heavy pressure in your chest as a result of exercise, walking, or other physical activity such as climbing a flight of stairs (Note: this does not include the normal out of breath feeling that results from normal activity)? Yes ____ No ____

3. Have you ever experienced rapid heart action or palpitations? Yes ____ No ____

4. Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction coronary insufficiency, or thrombosis? Yes ____ No ____

5. Have you ever had rheumatic fever? Yes ____ No ____

6. Do you have diabetes, high blood pressure, or sugar in your urine? Yes ____ No ____

7. Do you or anyone in your family have high blood pressure, or hypertension?
Yes ____ No ____

8. Do you have more than one blood relative (Parent, brother, sister, first cousin) have a heart attack or coronary artery disease before the age of 60? Yes ____ No ____

9. Have you ever taken any medication to lower your blood pressure? Yes ____ No ____

10. Have you ever taken medications or been on a special diet to lower your cholesterol level? Yes ____ No ____

11. Have you ever taken digitalis, quinine, or any other drug for your heart?
Yes ____ No ____

12. Have you ever taken nitroglycerin or any other tablets for chest pain - tablets that you take by placing under your tongue? Yes ____ No ____

13. Have you ever had an electrocardiogram that was not normal? Yes ____ No ____

14. 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 ____

15. Are you unaccustomed to vigorous exercise? Yes ____ No ____

16. Is there any reason not mentioned here why you should not follow a regular exercise program? If so, what is the reason:

_______________________________________________________________________

Smoking

Please check, which describes your current habits:

Non User ____ or Former User _____; Date Quit __________________________

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

Please describe any past or current musculoskeletal conditions you have incurred (i.e. 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 _______________________________________________________________

_________________________________________________________________________

Lower Leg/Ankle/Foot ______________________________________________________

_________________________________________________________________________

Nutritional

Are you on any specific food/nutritional plan at this time? Yes ____ No ____

If yes, please list: ________________________________________________________

Do you take dietary supplements/vitamins/minerals? Yes ____ No ____

If yes, please list: ________________________________________________________

Do you experience any frequent weight fluctuations? Yes ____ No ____

If yes, please give details: _________________________________________________

_________________________________________________________________________

For each of the statements below, choose the answer that most accurately describes your response based on the scale below:

(1) 4 or more times per day (2) 2 – 3 times per day
(3) Once per day (4) twice per week (5) less than twice per week

How often do you eat animal or vegetable protein foods such as meat, fish, poultry, eggs, milk, cheese, peanut butter, tofu, or legume? ______

How often do you eat broccoli, brussel sprouts, cabbage, cauliflower, or other vegetables in the cabbage family? ______

How often do you eat apples, bananas, berries, melons, citrus, and other fruits? ______

How often do you eat foods high in cholesterol such as processed meats, organ meats, cheese, eggs, whole milk, ice cream, sour cream, butter, shortening, etc.? ______

How often do you eat foods high in vitamin A such as spinach, carrots, yams, cantaloupe, and other green leafy or yellow vegetables or fruits? ______

How often do you eat foods high in vitamin C such as citrus fruits, tomatoes, strawberries, etc? ______

Exercise History Questionnaire

Are you currently involved in a regular exercise program? Yes ____ No ____

Do you regularly walk or run 1 or more miles continuously?
Yes ___ No ___

If yes, average number of miles you cover per workout or day: ____ miles

What is your average time per mile? ________ Minutes/Seconds

Do you practice weightlifting or home calisthenics? Yes ____ No ____

Are you involved in an aerobic program? Yes ____ No ____

Do you frequently compete in competitive sports? Yes ____ No ____

If yes, which one or ones?

Golf ____ Volleyball ____ Bowling ____ Football ____ Tennis ____ Baseball ____

Handball ____ Track ____ Soccer ____ Basketball ____

Other __________________________________________

Average number of times per week _______

In which of the following high school or college athletics did you participate?

None ____ Track ____ Football ____ Swimming ____ Basketball ____

Tennis ____ Baseball ____ Wrestling ____ Soccer ____ Golf ____

Other __________________________________________

What activities would you prefer in a regular exercise program for yourself?

Walking and/or running ____ Bicycling (outdoors) ____ Swimming ____

Stationary running ____ Stationary Biking ____ Tennis ____

Other __________________________________________

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

_______________________________________________________________________

Your family physician will be provided with a letter indicating your participation in a fitness program at Victoria Wellness. I hereby give my permission for this letter.
Yes ____ No ____ (please initial)

It may also be necessary for Victoria Wellness (Narina Prokosch, R.N.) to confer with your family physician should a medical reason arise. I hereby give my permission for this consultation. Yes ____ No ____ (please initial)

Please add my name to Victoria Wellness email list to be notified of newsletters or upcoming events. Yes ____ No ____

Signature _________________________________ Date ______________________