Health History Questionnaire

Personal Fitness Profile

Health History Questionnaire

Contact Information

First Name:
Last Name:
Address:
City, State, Zip:
Email:
Phone No:
Alternate Phone No:

Personal Information
Date of Birth:
Height:
Weight:
Gender:	Female Male

Emergency Contact
First Name:
Last Name:
Relationship:
Phone No:
Alternate Phone No:

Health Information

Are you pregnant?	yes no
Do you smoke?	yes no
Do you use smokeless tobacco?	yes no

Other conditions not listed:

Please explain any conditions you marked with an X.

Please list and explain any medical conditions, including surgery, for which a physician has ever recommended restrictions on activity.

Please list any medications or nutritional supplements that you take regularly and the reason for
taking them.

Describe your current exercise program. Please include information such as the type of activity,
sessions per week, minutes per session, and how long you have been doing the activity.

What are your health and fitness goals and objectives?

How did you hear about us?

Please state the starting time and date of the camp for which you have registered and whether
it will be for 3 days per week or 5 days per week.

Please check the applicable box if you have ever experienced any of the following:
Heart Disease	Cholesterol greater than 200	Hernia
Rheumatic Disease	Diagnosed Hypoglycemia	Cancer
Chest Pain	High Blood Pressure	Arthritis
Heart Attack	Heart Murmurs	Lung Disease
Stroke	Lightheadedness/Fainting	Back Pain
Epilepsy/Seizure Disorder	Joint, Tendon, or Muscle Pain	Shortness of Breath
Diabetes	Irregular Heartbeat	Bulemia or Anorexia

Personal Fitness Profile