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Medical History Questionnaire- Version 1
Name
*
Address
*
Work Phone
*
Home Phone
*
Age
*
Today's Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2022
2023
2024
2025
2026
Date of Birth
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
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1958
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1989
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1991
1992
1993
1994
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1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Sex
*
1. Family History
Indicate if any of your immediate family (parents, brothers, sisters, grandparents) have experienced any of the following, the age at which diagnosis occurred and the person's relationship to you.
High Blood Pressure
High Cholesterol
Heart Disease
Stroke
Diabetes
Cancer
Clotting or Bleeding Disorders
Coeliac Disease
2. Have you ever passed out or nearly passed out during or after exercise?
*
Yes
No
3. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
*
Yes
No
4. Does your heart ever race or skip beats (irregular beats) during exercise?
*
Yes
No
5. Has a doctor ever told you that you had a heart problem?
*
Yes
No
If so, check all that apply:
High Blood Pressure
High Cholesterol
Kawasaki Disease
Heart Murmur
Heart Infection
Other:
6. Has a doctor ever ordered a test for your heart? (For example: ECG/EKG, echocardiogram)
*
Yes
No
7. Do you get light-headed or feel more short of breath than expected during exercise?
*
Yes
No
8. Have you ever had an unexplained seizure?
*
Yes
No
9. Do you get more tired or short of breath more quickly than your friends during exercise?
*
Yes
No
10. Personal Medical History (indicate symptoms that apply to you)
*
Pain in lower legs when walking or climbing stairs
Frequent dizziness
Chronic cough
Frequent colds or flu
Frequent headaches
Frequent aches or pains in joints
Frequent backache
Joint pain
Stiffness/swelling in joints
Unusual bleeding or blood clots
No symptoms
Are you presently experiencing, or have you ever been treated by a doctor for any of the following?
11. Lung problems (Asthma/Emphysema/Bronchitis/Shortness of Breath/Other)
*
Yes
No
Details
12. Blood Pressure Problems
*
Yes
No
Details
13. Gut Problems (Coeliac Disease/Ulcer/Abdominal Pain/Diarrhea/Constipation/Hernia/Other)
*
Yes
No
Details
14. Urinary Problems (Renal Insufficiency/Burning/Difficulty with control of urine)
*
Yes
No
Details
15. Diabetes
*
Yes
No
Details
16. Blood Loss (In vomit/Sputum/Bowel Action/Urine)
*
Yes
No
Details
17. Heat Illness: Have you ever suffered from heat illness or heat stroke after exercise?
*
Yes
No
Details
18. Bone or Joint Injury (Back/Knee/Ankle/Hip/Shoulders)
*
Yes
No
Details
19. Have you had an operation recently?
*
Yes
No
Details
20. Have you suffered a musculoskeletal injury in the past 12 months?
*
Yes
No
Details
21. Do you have a past history of any sleep disorders?
*
Yes
No
22. Medication
(a) Are you taking any medication prescribed by your Doctor or other Health Care providor (including non-steroidal anti-inflammatory drugs)? If so, list details, ie, type of drugs, dosage.
(b) How often do you take over the counter medications such as aspirin, nurofen, etc.
*
Daily
Weekly
Occasionally
Never
23. Physical Activity: How many times per week do you exercise for at least 20 - 30 minutes continuously?
*
Do not have a regular program
Once per week
2 - 3 times per week
4 - 5 times per week
More than 5 times per week
24. Alcohol Consumption
(a) In the past two weeks list how many days you consumed an alcoholic beverage?
*
Did not drink in the past 6 months
Did not drink in the past two weeks
1 - 2 days
3 - 4 days
5 - 7 days
8 - 10 days
11 - 14 days
(b) In the past two weeks list how many drinks on average you had per day?
*
Did not drink in the past 6 months
Did not drink in the past two weeks
1 drink
2 - 3 drinks
4 - 6 drinks
7 or more drinks
25. Tobacco: How often do you use tobacco?
*
Never
Quit
Smoker
If Quit, When?
If Smoker: How many packs/day?
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