Current Member Yearly Update - Health History QuestionnaireΔContact Information:First NameLast NameI am over 18 years of age. Yes NoDate of Birth (Month)- Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDate of Birth (Day)- Select -12345678910111213141516171819202122232425262728293031Date of Birth (Year)PhoneEmailPrimary Care Information: Enter Primary Care Physician name and date of last visit.Primary Care Physician First/Last NamePrimary Care Practice NameDate of Last Visit (Month)- Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDate of Last Visit (Day)- Select -12345678910111213141516171819202122232425262728293031Date of Last Visit (Year)Specialist Physician Information: Enter Specialist Physician name and date of last visit.Specialist Physician First/Last NameSpecialist Physician Practice NameDate of Last Visit (Month)- Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDate of Last Visit (Day)- Select -12345678910111213141516171819202122232425262728293031Date of Last Visit (Year)Emergency Contact Information:Emergency Contact First NameEmergency Contact Last NameEmergency Contact PhoneOver the last 3 months, have you regularly participated in physical activity for at least 30 minutes, three days a week at moderate intensity? Yes NoIf yes, which of the following best describes any vigorous intensity activity in your regular routine over the last 3 months? I participate in some or all vigorous intensity activity None, but I want to begin some vigorous intensity activity None, but I want to continue moderate intensity activityIndicate by selecting YES or NO if you currently have or have had any of the following medical conditions:Heart Attack Yes NoHeart Surgery Yes NoCardiac Catheterization Yes NoCoronary Angioplasty (PTCA) Yes NoHeart Valve Disease Yes NoHeart Failure Yes NoHeart Transplantation Yes NoAbnormal Heart Rhythm Yes NoPacemaker/implantable cardiac defibrillator Yes NoPeripheral Vascular Disease (PVD or PAD) Yes NoCerebrovascular Disease - Stroke or TIA Yes NoType 1 or Type 2 Diabetes Yes NoRenal (kidney) Disease Yes NoCongenital Heart Disease Yes NoIndicate by selecting YES or NO if you have experienced any of the following signs or symptoms recently:Pain/discomfort in chest, neck, jaw or arms at rest or upon exertion Yes NoShortness of breath at rest or with mild exertion Yes NoDizziness or loss of consciousness during or shortly after exercise Yes NoShortness of breath occurring at rest or 2-5 hours after the onset of sleep Yes NoEdema in both ankles that is most evident at night or swelling in a limb Yes NoAn unpleasant awareness of forceful or rapid beating of your heart Yes NoPain in your legs or elsewhere while walking; more severe walking up stairs Yes NoKnown heart murmur Yes NoUnusual fatigue or shortness of breath with usual activities Yes NoIn accordance with The American College of Sports Medicine, high risk events and certain other risk factors will require clearance by your physician prior to your assessment and exercise prescription. Should you be required to seek physician clearance, yet elect NOT to, please check the consent box below. By checking the consent box, you will waive your assessment and exercise prescription. Failure to sign, when required, will preclude you from any activity or event at the Center. I acknowledge that I have a "high risk event(s)" and require physician clearance prior to participation. However, at this time I will NOT seek medical clearance and choose to continue to use Carle Health & Fitness Center at my own risk. I release IWP Bloomington, LLC d/b/a Carle Health & Fitness Center and Integrated Partners, LLC, its employees, affiliates and agents for any injury or illness that may occur as a result of my decision.E-SignatureIndicate by selecting YES or NO to all that apply:High Cholesterol Yes NoAsthma / Lung Disease Yes NoHigh Blood Pressure (controlled or treated) Yes NoBlood relative heart attack/surgery before 55 Yes NoFibromyalgia Yes NoConcussion Yes NoHernia Yes NoOsteopenia / Osteoporosis Yes NoParkinson's Disease Yes NoOrthopedic Issues Yes NoAre you currently a smoker? Yes NoCancer Yes NoSeizure Disorder Yes NoMultiple Sclerosis Yes NoMental Health Problems Yes NoAnemia Yes NoThyroid Disorder Yes NoVertigo Yes NoPlease list any Medications, Vitamins or Supplements you are currently taking:Please rate your readiness to make changes in the following areas:Weight Management No interest in making a change Plan to change in the next 6 months Plan to change this month Recently started working on this Doing this consistently (6+ months)Physical Activity No interest in making a change Plan to change in the next 6 months Plan to change this month Recently started working on this Doing this consistently (6+ months)Stress Management No interest in making a change Plan to change in the next 6 months Plan to change this month Recently started working on this Doing this consistently (6+ months)Overall Health No interest in making a change Plan to change in the next 6 months Plan to change this month Recently started working on this Doing this consistently (6+ months)Please explain your goals and why they are important to you:As stated in my Membership Contract (Part III - Waiver of Claims and Assumption of Risk Form) and explained to me by a representative of IWP Bloomington, LLC d/b/a Carle Health & Fitness Center, I understand and agree it is advisable for me to consult with my physician to assess my current health status and suitability for physical exercise. I certify, that to the best of my knowledge and belief, the information I provided on this Health History Questionnaire Form is complete and accurate.As stated in my Membership Contract (Part III - Waiver of Claims and Assumption of Risk Form) and explained to me by a representative of IWP Bloomington, LLC d/b/a Carle Health & Fitness Center, I understand and agree it is advisable for me to consult with my physician to assess my current health status and suitability for physical exercise. I certify, that to the best of my knowledge and belief, the information I provided on this Health History Questionnaire Form is complete and accurate and as I am under 18, I have permission from my Guardian.E-SignatureParent/Guardian E-SignatureSubmit Form