MEDICAL HISTORY AND SCREENING FORM by yoursovain

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									MEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY AND SCREENING FORM
General Information
Participant:




Family Physician and/or Primary Health Care Provider:




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Marital Status:
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Sex:
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Education:
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Occupation:
What is (are) your purpose (s) for participation in this Fitness Program?
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Present Medical History
Check those questions to which you answer yes (leave the others blank).
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Comments ___________________________________________________________________
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Do you now have or have you recently experienced:
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Comments ___________________________________________________________________
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Women only answer the following. Do you have:
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Comments ___________________________________________________________________
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Men and women answer the following:


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Past Medical History
Check those questions to which your answer is yes (leave others blank).
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Comments ___________________________________________________________________
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Family Medical History

Father:
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                 Good                 Fair         Poor
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Mother:
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Siblings:
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Familial Diseases




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Comments ___________________________________________________________________
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Other Heart Disease Risk Factors


Smoking


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Diet




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Comments ___________________________________________________________________
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Comments ___________________________________________________________________
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