Medical History Review Form – Mindset Fitness Training

Home
About Us
Contact
Forms
Personal Training
Shop

Home
About Us
Contact
Forms
Personal Training
Shop

Medical History Form

Today's Date

Date of Birth

Name

Street Address

Apartment, suite, etc

City

ZIP / Postal Code

Phone (Home)

Phone (Cell)

Phone (Work)

Emergency Contact

Phone

Occupation

Height

Weight

GenderMaleFemale

Physician's Name

Phone

Medical History

Please indicate if any of these statements apply to you (Past or Current)

Checkbox

Heart Problem(s): i.e Chest Pain, Heart Murmur, StrokeDiabetes MellitusAsthma, Breathing, or Lung ProblemsAllergiesCancer (other than skin)Seizures, Seizure Mdication, Neurological Problems, DizzinessHigh Blood PressureBack Problems, Joint or Muscle Disorder still affecting youRecent Surgery (Last 12 Months)Hernia or any condition that may be aggravated by exercisePhysician's advice not to exerciseHigh CholesterolFamily History of Coronary Artery Disease

Do you smoke tobacco products?YesNo

Do you consume alcoholYesNo

Are you on medication?YesNo

Do you take supplements of any kind?YesNo

Is stress from daily living an issue in your life?YesNo

Do you have joint problems that might be aggravated by exercise?YesNo

Skeletal Injuries

Neck

Back

Knee (Right, Left)

Head

Other Injuries

Shoulder (Right, Left)

Please describe any special considerations on how your injury currently affects your ability to function: (i.e illness or injury)

Surgery

Disclosure:

Please talk with your doctor by phone or in person before you start any new training program or have a fitness assessment. Tell your doctor about your health questionnaire and which questions you answered yes to.

Enter your name to confirm that to the best of your knowledge the above information is true:

Esign

Date Signed

Questions? Contact Us Today!

First Name *

Email Address *

Phone Number

Message0 / 180