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
Rheumatic Disease
  Diagnosed Hypoglycemia
Chest Pain
  High Blood Pressure
Heart Attack
  Heart Murmurs
  Lung Disease
  Back Pain
Epilepsy/Seizure Disorder
  Joint, Tendon, or Muscle Pain
  Shortness of Breath
  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.