Health History Questionnaire

Contact Information:

First Name

Last Name

I am over 18 years of age.

Yes

Date of Birth (Month)

Date of Birth (Day)

Date of Birth (Year)

Phone

Primary Care Information:

Enter Primary Care Physician name and date of last visit.

Primary Care Physician First/Last Name

Primary Care Practice Name

Date of Last Visit (Month)

Date of Last Visit (Day)

Date of Last Visit (Year)

Specialist Physician Information:

Enter Specialist Physician name and date of last visit.

Specialist Physician First/Last Name

Specialist Physician Practice Name

Date of Last Visit (Month)

Date of Last Visit (Day)

Date of Last Visit (Year)

Emergency Contact Information:

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Over the last 3 months, have you regularly participated in physical activity for at least 30 minutes, three days a week at moderate intensity?

Yes

If 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 activity

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

Heart Attack

Yes

Heart Surgery

Yes

Cardiac Catheterization

Yes

Coronary Angioplasty (PTCA)

Yes

Heart Valve Disease

Yes

Heart Failure

Yes

Heart Transplantation

Yes

Abnormal Heart Rhythm

Yes

Pacemaker/implantable cardiac defibrillator

Yes

Peripheral Vascular Disease (PVD or PAD)

Yes

Cerebrovascular Disease - Stroke or TIA

Yes

Type 1 or Type 2 Diabetes

Yes

Renal (kidney) Disease

Yes

Congenital Heart Disease

Yes

Indicate 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

Shortness of breath at rest or with mild exertion

Yes

Dizziness or loss of consciousness during or shortly after exercise

Yes

Shortness of breath occurring at rest or 2-5 hours after the onset of sleep

Yes

Edema in both ankles that is most evident at night or swelling in a limb

Yes

An unpleasant awareness of forceful or rapid beating of your heart

Yes

Pain in your legs or elsewhere while walking; more severe walking up stairs

Yes

Known heart murmur

Yes

Unusual fatigue or shortness of breath with usual activities

Yes

In 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-Signature

Indicate by selecting YES or NO to all that apply:

High Cholesterol

Yes

Asthma / Lung Disease

Yes

High Blood Pressure (controlled or treated)

Yes

Blood relative heart attack/surgery before 55

Yes

Fibromyalgia

Yes

Concussion

Yes

Hernia

Yes

Osteopenia / Osteoporosis

Yes

Parkinson's Disease

Yes

Orthopedic Issues

Yes

Are you currently a smoker?

Yes

Cancer

Yes

Seizure Disorder

Yes

Multiple Sclerosis

Yes

Mental Health Problems

Yes

Anemia

Yes

Thyroid Disorder

Yes

Vertigo

Yes

Please 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.

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-Signature

Parent/Guardian E-Signature