Personal Fitness Profile

Health History Questionnaire


Contact Information

 

Personal Information

Female Male
 

Emergency Contact



Health Information


yes no
yes no
yes no


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
 

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.