Download Medical History

Eat to Live Well
Participant Registration
Today’s Date: _______________
Please read and complete all pages of this form. Thank you.
Personal Information
Name: __________________________________________  Female  Male
Address: ___________________________________________________________
Date of Birth: _____________ Age: _______ Occupation: __________________
Home Phone: (_____)___________ Work Phone: (___)_________
Email Address: _________________________________________________
Emergency Contact Information
Notify: ________________________ Relationship: _________________________
Home Phone: (_____)___________ Work Phone: (___)______________
Physician Name: ____________________ Physician Phone: (_____)_____________
HEALTH SCREENING
1. Are you presently involved in a regular exercise program? ___Yes ___No
a. If yes, please list activity, duration, frequency and intensity:
2. Do you now have or have you ever smoked? ____Yes ____No
a. If you previously smoked, how long did you smoke, how often and when did you quit?
b. If you currently smoke, how much?
3. Do you drink caffeinated coffee or colas? _____Yes _____No
a. If yes, how much per day.
4. Do you now or have you ever been on a diet? _____Yes _____No
a. If yes, please explain:
5. Do you consider yourself overweight or underweight?
6. Number of meals you usually eat per day: _____
7. Do you usually eat breakfast? _____Yes _____No
8. Number of times per week you usually eat the following:
BEEF: ____ FISH: _____
PORK: ____ FOWL:_____
DESSERTS: ____FRIED FOODS: ____FAST FOODS: ____
9. Do you regularly use any of the following: (Please circle)
BUTTER
SUGAR
SWEETENERS
SALT
WHOLE MILK
10. How would you describe your nutrition habits? (Please circle)
GOOD
FAIR
POOR
11. Please describe your knowledge of exercise fitness: (Please circle)
VERY KNOWLEDGEABLE
KNOWLEDGEABLE
NO KNOWLEDGE
12. Please describe your knowledge of nutrition: (Please circle)
VERY KNOWLEDGEABLE
KNOWLEDGEABLE
NO KNOWLEDGE
13. Would you like to lose weight?
YES
NO
14. If so, how much weight do you want to lose? __________lbs
15. Why are you interested in losing weight now?
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16. What programs/products have you tried in the past?
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17. Why do you feel that these other program(s) did not work for you?
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18. Do you take vitamin or any type of nutritional supplements?______Yes ______No
19. How many glasses of water do you drink daily?________
20. Do you eat out?_____Yes _____No
How Often?_________________________
21. Where is your energy level, on a scale of 1 -10 (1 = dragging)_________________
FITNESS GOALS
Please describe your specific goals and dates for achieving them:
_____Improve strength
_____Improve flexibility
_____Improve cardiovascular fitness
_____Improve muscle tone and shape
_____Improve diet/eating habits
_____Lose weight/inches
_____Gain weight/muscle
_____Reduce stress
_____ Increase energy
_____ Stop smoking/drinking_____ Additional goals (Please list)
Medical History
Section One: Major Cardiovascular Risk Factors
Age: Male older than 45 or Female older than 55
Smoking: Smokeless tobacco, cigarettes, cigars, or pipe
Blood Pressure: Greater than 140/90 Do you know your blood pressure __yes __no
Cholesterol: Greater than 240
Family History: Heart Attack – Father/Brother before age 55, Mother/Sister before age 65
Physical Inactivity: You get less than 30 min of physical activity fewer than 3 days per week
Obesity: You are more than 30 pounds overweight
Diabetes: You are diabetic or are on medication to control your blood sugar
Section Two: Medical History:
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High Blood Pressure
Hepatitis
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Epilepsy
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Tuberculosis
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Heart Condition
Cancer
Arthritis
Diabetes
Respiratory Problems
Fracture
Stroke
Knee Problems
Back Problems
Shoulder Problems
Neck Problems
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Other
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Section Three: Current Symptoms or Conditions:
Experiencing chest discomfort with exertion
Experiencing unreasonable shortness of breath
Experiencing dizziness, fainting, or blackouts
Have any muscular problems or disorders
List: _________________________________________________________
Have any bone or joint problems
List: _________________________________________________________
Take heart or blood pressure medication
Are currently pregnant
Have concerns about the safety of exercise
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Please list currant medications/dietary supplements
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Please list date of last physical examination and results:
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If you checked any of the above boxes, please explain below:
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Client Signature _______________________________ Date: _____________
Doctors Signature_____________________________ Date: _____________
** ”D Wellness, L.L.C. reserves the right to refuse service to or participation by anyone.”