Current Member Yearly Update - Health History Questionnaire

Carle Health & Fitness Center

Contact Information:


Primary Care Information:

Enter Primary Care Physician name and date of last visit.


Specialist Physician Information:

Enter Specialist Physician name and date of last visit.


Emergency Contact Information:



Indicate by selecting YES or NO if you currently have or have had any of the following medical conditions:


Indicate by selecting YES or NO if you have experienced any of the following signs or symptoms recently:


Indicate by selecting YES or NO to all that apply:


Please rate your readiness to make changes in the following areas: