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					TERMS AND CONDITIONS:
1. The information given on the medical history questionnaire is correct to the best of my knowledge. I understand that absence of the physical problems listed on this form does not necessarily guarantee that I am in satisfactory health to participate in Crossroads Bible Church activities. ______ (Initials)
**All information in this Questionnaire is confidential, and will remain confidential and not be discussed with anyone other than the person it is intended for. This Questionnaire is used solely for the purpose of assessing current fitness levels, risk factors, and motivation.**

PERSONAL INFORMATION Name: _______________________ Signature: ___________________ Date: _________

Parent/Guardian Name: _______________ Signature: ________________ Date: _________ (If under 18 years, parent or guardian signature is required) Sex: Male Female Date of Birth: _____ / _____ / _____

Address: __________________________ City: _______________ State: _____ Zip: _______ Home Phone: (_____) _____ - _______ Email: ___________________________ EMERGENCY CONTACT Name: _________________________________________ Relationship: ______________________ Day Phone: ( _____ ) _____ - ________ Night Phone: ( _____ ) _____ - ________ Family Physician Physician’s Name: _____________________ Work Phone:(_____) _____ - ________

Physician’s Phone: ____________

Physician’s Address: _________________ City: ____________ State:___ Zip Code:________

CURRENT HEALTH STATUS Age: ______ Height ______ Weight ______

Have you experienced any of the following: (Please check the box of those questions to which your answer is yes. Leave others blank.)
**Medical clearance required

Asthma?** Pain in your chest when doing physical activity? Back Pain? Pain in your chest when not doing activity? Dizziness or fainting spells? Are you Currently pregnant?** High Blood Pressure? (> 140/90) Low blood pressure? High cholesterol? (>200) Diabetes or impaired fasting Glucose (>110) Any stomach or intestinal problems? Kidney Problems?

Heart trouble, heart attack or coronary? Any significant stress/depression? Swollen, stiff, painful joints? Arthritis? Feel shortness of breath during little or no exertion? A chronic, or morning cough? Heartburn, ulcers, constipation, diarrhea? Other joint or muscle problems? Are your ankles often badly swollen? Menstrual problems? (optional) Increased Fatigue or difficulty sleeping? Leg cramps or pain after walking short distances? Migraine or recurrent headaches?

MEDICATIONS List any medications you are currently taking (Including self-prescribed- Advil,Vitamins,etc) Please list Reason _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ TOBACCO USE Do you presently use tobacco products? Yes No If you do use, what type: _______________ Amount per day: _______ Age started: ________ Have you ever used tobacco products? Yes If you quit, when? Month _______________ LIFESTYLE (please circle how often) Do you drink alcohol? Beer Never Hard Alcohol Never Wine Never PAST MEDICAL HISTORY Have you ever been diagnosed with any of the following: Heart murmur or problems Thyroid problems Diabetes or abnormal blood sugar test Stroke Epilepsy or seizures No (if no, skip next question) Year ___________

Rarely Rarely Rarely

1-2x/wk 1-2x/wk 1-2x/wk

3-4x/wk 3-4x/wk 3-4x/wk

Daily Daily Daily

Diseases of the arteries Cancer Other lung diseases Hernia Major musculoskeletal injuries

List any medical tests or hospitalizations you have had in the last 2 years: Reason __________________________________________________________ _________________________________ __________________________________________________________ _________________________________ ____________________________________________________________________________________________ Please explain any past or present injuries, muscle or joint soreness, or limitations you’ve experienced? ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

FAMILY HISTORY Father: Alive Current age _____ General health: Deceased Age at death _____

Excellent

Good

Fair

Poor

Don’t know

Cause of death or reason for poor health: __________________________________________________________ Mother: Alive Current age _____ General health: Deceased Age at death _____ Excellent Good Fair Poor Don’t know

Cause of death or reason for poor health: __________________________________________________________ Have any of your blood relatives had any of the following? (Exclude cousins, half-relatives, or relatives by marriage) Heart attacks or strokes before age 55 Congenital heart failure High blood pressure Heart operations High cholesterol or low HDL Cancer before age 50 Diabetes Obesity (20 or more pounds overweight)

EXERCISE Are you currently involved in a regular training program? Frequency (x / wk) ______________ ______________ ______________

Yes

No

Cardiovascular Strength training Flexibility

Duration (minutes, miles, etc / session) Type of exercise _____________________________________________ _____________________________________________ _____________________________________________

Assess your overall fitness in each of the categories: Cardiovascular Strength Flexibility Excellent Excellent Excellent Good Good Good Fair Fair Fair Poor Poor Poor Don’t know Don’t know Don’t know

1) When were you in the best shape of your life? _____________________________________ 2) When did you first start thinking about getting in shape? _____________________________ 4) What if anything stopped you in the past? _________________________________________ GOAL SETTING Where do you rate your health in your life? How committed are you to achieving your fitness goals? Please circle all the activities that interest you
Aerobic Fitness Classes Swimming Cross Country Skiing Baseball Marathons Triathlons Kayaking Pilates Football Tennis Soccer Yoga Golf Snowboarding Hiking Running Walking Volleyball

Low Priority Very

Medium Priority Semi

High Priority Not Very

Please list in order of priority, the fitness goals you would like to achieve in the next 3-12 months? 1.) __________________________________________________________________________________ 2.) __________________________________________________________________________________ 3.) __________________________________________________________________________________

Thank you for taking the time to complete and return this form prior to your appointment


				
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