Center For Athletes Health and Fitness History Form

1. Are you presently involved in a regular exercise program?

If yes, please list activity, duration, frequency, and intensity:

2. Do you now smoke or have you ever smoked?
a. If you previously smoked,
How long did you smoke?
How often?
When did you quit?
b. If you currently smoke, how much?

3. Do you use alcohol?
If yes,
How much per day?
How much per week?

4. Check any conditions or diseases you now have or have had in the past.
Heart attack; coronary bypass or other cardiac surgery		Cold hands or feet
Diabetes		Unusual shortness of breath
Stroke		Light-headedness or fainting
Peripheral vascular disease		Epilepsy or seizures
Phlebitis or emboli		Anemia
Rheumatic fever		Asthma
High blood pressure		Emphysema
Low blood pressure		Bronchitis
Chest discomfort		Pneumonia
Extra, skipped, or rapid heart beats		A chronic recurrent cough
Heart murmur		Increased stress or depression
Ankle swelling		Emotional disorders
Trouble sleeping		Fatigue or lack of energy
Migraine or recurrent headaches		Ulcers
Swollen, stiff or painful joints		Stomach / intestinal problems
Foot problems		Hernia
Back problems		Limited motion in joints
Shoulder problems		Arthritis
Neck problems		Bursitis
Broken bones		Tendonitis
If you checked any of these, please explain here.


5. Please list any prescribed medications you are now taking.


6. Please list any over-the-counter medications or dietary supplements you are now taking.


7. Please list any illness, hospitalization, or surgical procedure within the past 2 years.


8. Please check specific goals you would like to achieve:
Improve strength		Reduce stress
Improve flexibility		Increase energy
Improve cardiovascular fitness		Stop smoking/drinking
Improve muscle tone and shape		Injury prevention
Improve diet/eating habits		Rehabilitate injury
Lose weight		Gain weight/muscle
Improve athletic performance
Additional goals (Please list):