Health History Questionnaire

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Introduction

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Physical Activity Readiness Questionnaire

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the questions below. If you are between the ages of 15- 69, the Physical Activity Readiness Questionnaire will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly.

Please check the following statements if they apply to you:

I have high blood pressure

I take blood pressure medication

I have high cholesterol

My father or brother had a heart attack or heart surgery prior to age 55

My mother or sister had a heart attack or heart surgery prior to age 65

Has your doctor ever said that you have a heart condition and recommendd only medically supervised physical activity?

Do you frequently have pains in your chest when you perform physical activity?

Have you had chest pain when you were not doing physical activity?

Do you ever lose your balance due to dizziness or do you ever lose consciousness?

Do you have a bone, joint, or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program?

Do you have any respiratory ailments?

Have you given birth within the last 6 months?

Have you had a recent surgery?

I didn't click any of the statements asked in the Physical Activity Readiness Questionnaire.

Correct

If you have marked YES to any of the above, please elaborate below:

If you answered yes to any of the above:

Talk with your doctor by phone or in-person BEFORE you start becoming more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the Physical Activity Readiness Questionnaire and which questions you answered YES. 1) You may be able to do any activity you want – as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. 2) Find out which programs are safe and helpful for you.

If you didn't click any of the statements above:

If you didn’t click any of the statements above honestly to all the Physical Activity Readiness Questionnaire questions, you can be reasonably sure that you can: 1) Start becoming more physically active – begin slowly and build up gradually. This is the safest and easiest way to go. 2) Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active. 3) If your health changes so that you then answer YES to any of these questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

Medical Information

Please check if you have any of the following:

Anemia

Arthritis

Cholesterol

Diabetes

Epilepsy

Heart condition

Hernia

Obesity

Pregnancy, or planning pregnancy

Thyroid problems

Heart attack

Ulcer

Other

What other medical conditions do you have the list above didn't mention?

I do not have any medical conditions to list.

Correct

Allergies

Please list any known allergies

Medications

Are you currently taking any medications?

Yes

Please list the medications you are taking currently.

Medication | Condition | Prescribing Physician

Injuries

Please mark any of the following areas in which you have pain or have experience previous injuries:

Left wrist

Right wrist

Left elbow

Right elbow

Left shoulder

Right shoulder

Neck

Upper back

Lower back

Right hip

Left hip

Right knee

Left knee

Right ankle

Left ankle

Other

Please describe your injuries

I do not have any injuries to list.

Correct

Lifestyle

Do you smoke?

Yes

Do you exercise more than 1.5 hours per week?

Yes

How many hours on average do you spend toward physical fitness per week?

I am a happy person.

Always

Sometimes

Never

I live a stress-free life.

Always

Sometimes

Never

I am physically actives 3 times per week.

Always

Sometimes

Never

I am consistently motivated to exercise.

Always

Sometimes

Never

I get more than seven hours of sleep most nights.

Always

Sometimes

Never

I get annual health checkups.

Always

Sometimes

Never

I follow a strict diet.

Always

Sometimes

Never

I exercise

intensively at my job or for recreation.

moderately at my job or for recreation.

little or none at my job or for recreation.

What exercises do you enjoy, or have you enjoyed in the past?

If you do not exercise in the general sense and intensively work at your job; please say that below. If you do both, please let me know that also.

Please list reasons why you do not exercise regularly:

I eat 2-3 servings of meat a day

Always

Sometimes

Never

I eat 6-10 servings of grains a day

Always

Sometimes

Never

I eat 3-4 servings of fruit a day

Always

Sometimes

Never

Anything else you'd like me to know about?

I know it is my responsibility to seek medical advice before starting my health and wellness journey If I answered YES to any of the questions in the Physical Activity Readiness Questionnaire, medical conditions, or have injuries that may prevent you be successful.(Required)

Yes

I have fully disclosed all requested information in an honest manner.(Required)

Yes

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Entering your initials signifies that you are signing this document.

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Empower Your Body: A Beginner’s Guide to Fitness

Starting point

Introduction

Physical Activity Readiness Questionnaire

If you answered yes to any of the above:

If you didn't click any of the statements above:

Medical Information

Medications

Injuries

Lifestyle