Athlete Health Questionnaire Your answers to these questions help me understand your health and injury history. Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Email(Required) Occupation(Required)Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?(Required) Yes No Do you feel pain in your chest when you do physical activity?(Required) Yes No In the past month, have you had chest pain when you were not doing physical activity?(Required) Yes No Do you lose your balance because of dizziness or do you ever lose consciousness?(Required) Yes No Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?(Required) Yes No Is your doctor currently prescribing drugs for your blood pressure or heart condition?(Required) Yes No Do you know of any other reason why you should not do physical activity?(Required) Yes No Have you had or do you presently have any of the following conditions (check if yes):(Required) Rheumatic fever Edema High blood pressure Low blood pressure Injury to back or knees Seizures Lung disease Heart attack High cholesterol Fainting or dizziness Stroke Known heart murmur Palpitations or tachycardia Shortness of breath Diabetes Chest Pains Recent surgery None of the above If yes to any of the above, please explain:Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions?(Required) Heart condition High blood pressure High cholesterol Diabetes Major illness None of the above Date of your last physical examination performed by a physician?(Required) MM slash DD slash YYYY On a typical day do you do a lot of (check all that apply)?:(Required) Sitting Standing Bending Lifting Repetitive movements None of the above Do you participate in a regular exercise program at this time? If yes, please describe activity and frequency over last the 4 weeks and over the last 6 months:(Required)Have you ever performed resistance training exercises in the past?(Required) Yes No Do you have injuries (bone or muscle disabilities) that may interfere with exercising? If yes, briefly describe.(Required)Do you smoke? If yes, how much/how many times per day and at what age did you start?(Required)Please list any medications and supplements you are taking (including self-prescribed):(Required)What is your height?(Required)What is your body weight?(Required)What was your body weight a year ago?(Required)What was your body weight at age 21?(Required)In general, how do you feel about your weight/body image?(Required)Do you follow or have you recently followed any specific dietary intake plan and in general, how do you feel about your nutritional habits?(Required)Are there any injuries or limitations that have not been discussed up to this point?(Required)What are your top 3 goals listed from most important to least important (ex. Running goal, lose weight, gain muscle, improve in sport)?(Required)Are there any other questions, concerns, or health/fitness/medical history issues in the past that have not been mentioned, that your coach should be aware of?(Required)Signature(Required)
