shaheen,s blog: Medical History Questionnaire

Medical History Questionnaire

This is your medical history form, to be completed prior to your first training session. All information will be kept confidential. This information will be used for the evaluation of your health and readiness to begin our exercise program. The form is extensive, but please try to make it as accurate and complete as possible. Please take your time and complete it carefully and thoroughly, and then review it to be certain you have not left anything out. Your answers will help us design a comprehensive program that meets your individual needs.

If you have questions or concerns, we will help you with those after this form is completed. We realize that some parts of the form will be unclear to you. Do your best to complete the form. Your questions will be thoroughly addressed afterwards. It might be helpful for you to keep a written list of questions or concerns as you complete the medical history form.

Name: Shahana Begum____________________________________________________

Date: 4/12/2013__________________________________

MEDICAL HISTORY AND SCREENING FORM

General Information

Participant:

Name Shahana Begum___________________________________________________________

Address 1234 Main St, Toronto, ON __________________________________________________

Contact phone numbers (416)-123-4567_________________________________________________

Birth date 12/03/1979________________________________________________________________

Family Physician and/or Primary Health Care Provider:

Doctor/Other Dr. Ronald Ross_________________ Phone (416)-098-7654___________________

Address 54 Bloor St________________________ City Toronto___________________________

May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?

ü Yes o No

Signature:_________________________________________________________________________

Marital Status:

o Single ü Married o Divorced o Widowed

Sex:

o Male ü Female

Education:

o Grade School o Jr. High School o High School

ü College (2-4 years) o Graduate School o Degree _______________

Occupation:

Position General Worker_____________________ Employer Linsey Foods_________________

Address 97 Eglinton Ave____________________________________________________________

Phone (647) 658 8952_____________________________________________________________

What is (are) your purpose (s) for participation in this Fitness Program?

ü To determine my current level of physical fitness and to receive recommendations for an exercise program.

o__ Other (please explain) ________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Present Medical History

Check those questions to which you answer yes (leave the others blank).

¨ Has a doctor ever said your blood pressure was too high?

ü Do you ever have pain in your chest or heart?

¨ Are you often bothered by a thumping of the heart?

ü Does your heart often race?

¨ Do you ever notice extra heartbeats or skipped beats?

¨ Are your ankles often badly swollen?

ü Do cold hands or feet trouble you even in hot weather?

ü Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary?

¨ Do you suffer from frequent cramps in your legs?

ü Do you often have difficulty breathing?

¨ Do you get out of breath long before anyone else?

¨ Do you sometimes get out of breath when sitting still or sleeping?

¨ Has a doctor ever told you your cholesterol level was high?

¨ Has a doctor ever told you that you have an abdominal aortic aneurysm?

¨ Has a doctor ever told you that you have critical aortic stenosis?

Comments: ___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Do you now have or have you recently experienced:

¨ Chronic, recurrent or morning cough?

¨ Episode of coughing up blood?

ü Increased anxiety or depression?

¨ Problems with recurrent fatigue, trouble sleeping or increased irritability?

ü Migraine or recurrent headaches?

¨ Swollen or painful knees or ankles?

¨ Swollen, stiff or painful joints?

¨ Pain in your legs after walking short distances?

¨ Foot problems?

¨ Back problems?

¨ Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea?

¨ Significant vision or hearing problems?

¨ Recent change in a wart or a mole?

¨ Glaucoma or increased pressure in the eyes?

¨ Exposure to loud noises for long periods?

¨ An infection such as pneumonia accompanied by a fever?

¨ Significant unexplained weight loss?

ü A fever, which can cause dehydration and rapid heart beat?

¨ A deep vein thrombosis (blood clot)?

¨ A hernia that is causing symptoms?

¨ Foot or ankle sores that won’t heal?

¨ Persistent pain or problems walking after you have fallen?

¨ Eye conditions such as bleeding in the retina or detached retina?

¨ Cataract or lens transplant?

¨ Laser treatment or other eye surgery?

Women only answer the following. Do you have:

¨ Menstrual period problems?

¨ Significant childbirth - related problems?

¨ Urine loss when you cough, sneeze or laugh?

Date of the last pelvic exam and / or Pap smear _________________________________________

Are you on any type of hormone replacement therapy? No______________________________________

Men and women answer the following:

List any prescription medications you are now taking: N/A_______________________________________
_____________________________________________________________________________
_____________________________________________________________________________

List any self-prescribed medications, dietary supplements, or vitamins you are now taking: N/A_______
_____________________________________________________________________________
_____________________________________________________________________________

Date of last complete physical examination: __________________________________________________

o Normal o Abnormal o Never ü Can’t remember

Date of last chest X-ray: Sept 2012__________________________________________________________

ü Normal o Abnormal o Never o Can’t remember

Date of last electrocardiogram (EKG or ECG): June 2011_______________

ü Normal o Abnormal o Never o Can’t remember

Date of last dental check up: _____________________________

o Normal o Abnormal o Never ü Can’t remember

List any other medical or diagnostic test you have had in the past two years: N/A___________________
_____________________________________________________________________________
_____________________________________________________________________________

List hospitalizations, including dates of and reasons for hospitalization: N/A________________________
_____________________________________________________________________________
_____________________________________________________________________________

List any drug allergies: N/A_________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Past Medical History

Check those questions to which your answer is yes (leave others blank).

¨ Heart attack if so, how many years ago? ________

¨ Rheumatic Fever

¨ Heart murmur

¨ Diseases of the arteries

¨ Varicose veins

¨ Arthritis of legs or arms

ü Diabetes or abnormal blood-sugar tests

¨ Phlebitis (inflammation of a vein)

¨ Dizziness or fainting spells

¨ Epilepsy or seizures

¨ Stroke

¨ Diphtheria

¨ Scarlet Fever

¨ Infectious mononucleosis

¨ Nervous or emotional problems

¨ Anemia

¨ Thyroid problems

¨ Pneumonia

¨ Bronchitis

ü Asthma

¨ Abnormal chest X-ray

¨ Other lung disease

¨ Injuries to back, arms, legs or joint

¨ Broken bones

¨ Jaundice or gall bladder problems

Family Medical History

Father:

ü Alive Current age 65__________

My father's general health is:

o Excellent o Good ü Fair o Poor

Reason for poor health: Age________________________________________________________

o Deceased o Age at death _____________

Cause of death:__________________________________________________________________________

Mother:

ü Alive Current age 60__________

My mother's general health is:

o Excellent ü Good o Fair o Poor

Reason for poor health:_____________________________________________________

o Deceased o Age at death _____________

Cause of death: __________________________________________________________________________

Siblings:

Number of brothers _N/A_____ Number of sisters _N/A___ Age range __________________________

Health problems N/A______________________________________________________________________

Familial Diseases

Have you or your blood relatives had any of the following (include grandparents, aunts and uncles, but exclude cousins, relatives by marriage and half-relatives)?

Check those to which the answer is yes (leave other blank).

¨ Heart attacks under age 50

¨ Strokes under age 50

¨ High blood pressure

¨ Elevated cholesterol

ü Diabetes

ü Asthma or hay fever

¨ Congenital heart disease (existing at birth but not hereditary)

¨ Heart operations

¨ Glaucoma

¨ Obesity (20 or more pounds overweight)

¨ Leukemia or cancer under age 60

Other Heart Disease Risk Factors

Smoking

Have you ever smoked cigarettes, cigars or a pipe?

o Yes ü No

(If no, skip to diet section)

If you did or now smoke cigarettes, how many per day? _____________ ______________ Age started

If you did or now smoke cigars, how many per day? ________________ Age started______________

If you did or now smoke a pipe, how many pipefuls a day? ___________ Age started ______________

If you have stopped smoking, when was it? __________________________________________________

If you now smoke, how long ago did you start? _______________________________________________

Diet

What do you consider a good weight for yourself? 65 kg________________________________________

What is the most you have ever weighed (including when pregnant)? 75 kg_________________________

How old were you? 25________________

My current weight is: 69 kg_____________

One year ago my weight was: 68 kg_____

At age 21 my weight was: 60 kg________

Number of meals you usually eat per day: 3

Number of times per week you usually eat the following:

Beef 3_____________ Fish 4_____________ Desserts 1___________

Pork N/A___________ Fowl 1_____________ Fried Foods 3________

Number of servings (cups, glasses, or containers) per week you usually consume of:

Homogenized (whole) milk 4___________ Buttermilk 1___________________ Skim (nonfat) milk 1______

2% (low-fat) milk N/A_________________ 1% (low-fat) milk N/A____________ Coffee 7________________

Tea (iced or not) N/A_________________ Regular or diet sodas 2__________ Glasses of water 50_______

Do you ever drink alcoholic beverages?

o Yes ü No

If yes, what is your approximate intake of these beverages?

Beer:

o None o Occasional o Often If often, _____ per week

Wine:

o None o Occasional o Often If often, _____ per week

Hard Liquor:

o None o Occasional o Often If often, _____ per week

At any time in the past, were you a heavy drinker (consumption of six ounces of hard liquor per day or more)?

o Yes ü No

Do you usually use oil or margarine in place of high cholesterol shortening or butter?

ü Yes o No

Do you usually abstain from extra sugar usage?

o Yes ü No

Do you usually add salt at the table?

ü Yes o No

Do you eat differently on weekends as compared to weekdays?

ü Yes o No

shaheen,s blog

Wednesday, 4 December 2013

Medical History Questionnaire

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