Health Status Questionnaire – Get Fit Now • 860-614-7664

Name and contact details *

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D.O.B. *

Person to contact in case of emergency: *

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Heart History - Please check all that apply. *

Symptoms - Please check all that apply. *

Additional Health Issues - Please check all that apply. *

You have asthma or other lung disease (e.g., emphysema)
You have burning or cramping sensations in your lower legs with little physical activity
You have joint problems (e.g., arthritis) that limit your physical activity
You have concerns about the safety of exercise
You take prescription medications
You are pregnant
None of the Above

Other medical issues or concerns:

Risk Factor Assessment Risk factors for Coronary Heart Disease. Please check all that apply.

You are a man older than 45 years.
You are a woman older than 55years, have had a hysterectomy or are postmenopausal.
You have diabetes (Type 1 or Type 2)
You smoke or quit smoking within the previous 6 months.
Your blood pressure is greater than 140/90 mmHg.
Your blood cholesterol is greater than 200 mg
You have a close male blood relative (father or brother) who had a heart attack or heart surgery before the age of 55 or a close female blood relative (mother or sister) who had a heart attack or heart surgery before the age of 65.
You are physically inactive (you get less than 30 minutes of exercise 3 days a week).
Your waist circumference is greater than 40 in. (101.6 cm) if you are a man or greater than 35 in. (88.9 cm) if you are a woman.

Medications - Are you currently taking any medication(s)? *

If yes, please list all of your prescribed medications and how often you take them (whether daily (D) or as needed (PRN).

Of the medications you have listed, are there any you do not take as prescribed? *

Physical Activity Patterns and Objectives

List your specific goals for your exercise program:

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