Medical History Questionnaire

Name

First

Last

Address

Address 2

City/Town

State/Province

Preferred Phone Number

Age

Today's Date

Date of Birth

Sex

Family History

Indicate if any of your immediate family (parents, brothers, sisters, grandparents) have experienced any of the following, the age at which diagnosis occurred and the person's relationship to you.

High Blood Pressure

High Cholesterol

Heart Disease

Stroke

Diabetes

Cancer

Clotting or Bleeding Disorders

Coeliac Disease

Have you ever passed out or nearly passed out during or after exercise?

Yes

Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

Yes

Does your heart ever race or skip beats (irregular beats) during exercise?

Yes

Has a doctor ever told you that you had a heart problem?

Yes

If so, check all that apply:

High Blood Pressure

High Cholesterol

Kawasaki Disease

Heart Murmur

Heart Infection

Other

Other Heart Condition

Has a doctor ever ordered a test for your heart? (For example: ECG/EKG, echocardiogram)

Yes

Do you get light-headed or feel more short of breath than expected during exercise?

Yes

Personal Medical History (indicate symptoms that apply to you)

Pain in lower legs when walking or climbing stairs

Frequent dizziness

Chronic cough

Frequent colds or flu

Frequent headaches

Frequent aches or pains in joints

Frequent backache

Joint pain

Stiffness/swelling in joints

Unusual bleeding or blood clots

No symptoms

Medication

Are you taking any medication prescribed by your Doctor or other Health Care providor (including non-steroidal anti-inflammatory drugs)? If so, list details, ie, type of drugs, dosage.

How often do you take over the counter medications such as aspirin, nurofen, etc.

Daily

Weekly

Occasionally

Never

Physical Activity: How many times per week do you exercise for at least 20 - 30 minutes continuously?

Do not have a regular program

Once per week

2 - 3 times per week

4 - 5 times per week

More than 5 times per week

Tobacco: How often do you use tobacco?

Never

Quit

Smoker

When Did You Quit Smoking?

How many packs/day?

Family History

Are you presently experiencing, or have you ever been treated by a doctor for any of the following?

Medication

Alcohol Consumption