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Health History Questionnaire

Todays Date * required

Name

Address

Phone (home)

Phone (cell)

Phone (work)

Occupation

Place of work

Email

Date of Birth * required

Height

Weight

Age

Sex

Person to contact in case of emergency

Name

Phone

PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY

High Blood Pressure

Diabetes

Liver Disease

Pregnant

Shortness of Breath

Back Problems

Heart Problems

Joint Problems

Fractures

Smoker

Recent Surgery

Arthritis

Post-Partum

Seizures

Cancer

Asthma

Chronic Illness

Allergies

Neurological

Respiratory

Hernia

Scoliosis

Balance

If you have checked any of the above, please explain.

Current Medications

How did you hear about us?

What are your fitness goals?

Are there any other things you would like to tell us about your health?

Have you had a bone density test?

If so, when, and what was the result?

Current physical activity level and exercises

Are you under the care of a physician, chiropractor, or massage therapist for musculoskeletal?

If yes, reasons and results

List any major surgeries or illnesses

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Home
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(352) 612-3372

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Gainesville, FL 32606

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