KLUBZ FITNESS MEDICAL & HEALTH HISTORY
E-Mail:
Name:
Birthdate:
Age:
Height:
Weight:
Physician Name:
Physician Address (Below):
Street:
City:
State:
Zip:
Phone:
Date of last physical exam?:
Are you currently under a physicians care?: YesNo
If yes, explain:
Have you had an exercise stress test?: YesNo
If yes, what were the results?: NormalAbnormal
Any recent surgeries? If so, please describe and give dates below:
Other medical problem/considerations, recent illness(es), hospitalizations(s), or injury? If so, please describe and give dates below:
Do you know of any medical or health conditions, considerations, or circumstances that might make it dangerous or unwise for you to participate in an exercise program?
Emergency Contact:
Relationship:
Phone:

HEALTH HISTORY Please indicate your history related to each of the following conditions by checking the appropriate box. If you have had any condition in the past, please indicate the date in the appropriate space.
Condition:		If YES comment:
Heart murmur, clicks, or other cardiac findings	YesNo
Frequent extra, skipped, or rapid heart beats/palpitations	YesNo
Heart attack, coronary bypass, or other cardiac surgery	YesNo
Chest pain/angina (especially upon exertion)	YesNo
Currently pregnant (or within the last year)	YesNo
Diagnosed with high blood pressure	YesNo
Leg cramps during exercise	YesNo
Chronic swollen ankles	YesNo
Varicose veins	YesNo
Frequent dizziness/fainting	YesNo
Blood clot	YesNo
Severe arthritis	YesNo
Unexplained weight loss or gain	YesNo
Chronic back pain	YesNo
Musculoskeletal problems(s) or complaint(s)	YesNo
Asthma	YesNo
High cholesterol	YesNo
Emphysema	YesNo
Chronic fatigue	YesNo
Cancer	YesNo
Diabetes	YesNo
Epilepsy	YesNo
Rheumatic Fever	YesNo
Scarlet Fever	YesNo
Bronchitis	YesNo
Stroke	YesNo
Pneumonia	YesNo
Other	YesNo
Other	YesNo
Other	YesNo
Additional Comments:
MEDICATIONS Include any over the counter medications or other drugs you are currently taking

NAME	DOSAGE	PURPOSE	FOR HOW LONG?
ORTHOPEDIC HISTORY Please list any current problems/chronic conditions or past orthopedic surgeries:
Neck	Shoulder/Clavicle	Arm/Elbow	Wrist/Hand
Ribs/Chest	Spine/Back	Pelvis	Thigh/Hips
Knee/Patella	Lower Leg	Ankle	Foot/Toes
If you have checked any of the above please elaborate below: