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Health Status Questionnaire-OLD

GET FIT NOW, LLC
HEALTH STATUS QUESTIONNAIRE

This questionnaire identifies adults for whom physical activity might be inappropriate or adults who should seek physician consultation before beginning a regular physical activity program.

Section I: Personal and Emergency contact information

Feet/Inches
Lbs.

Person to contact in case of emergency:

Section 2: General Medical History

Please check all that apply. If none of these conditions apply, please check N/A.
Please check all that apply. If none of these conditions apply, please check N/A.
Please check all that apply. If none of these conditions apply, please check N/A.
Please use this area to describe any other health issues or concerns regarding your physical activity program.

Section 3: Risk Factor Assessment

Please check all that apply. If none of these conditions apply, please check N/A.

Section 4: Medications

Section 5: Physical Activity Patterns and Objectives

Please inform the fitness professional immediately of any changes that occur in your health status.

PATIENT INFORMATION RELEASE FORM

If you have answered yes to questions indicating that you have significant cardiac, pulmonary, metabolic, or orthopedic problems that may be exacerbated with exercise, you agree that it is permissible for us to contact your physician regarding your health status.

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