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TARGETING FITNESS
HEALTH HISTORY QUESTIONNAIRE
- Name: __________________________________________ Date: ______________________
- Work Phone: _________________________________________
- Sex: M____ F____ Age:_____
- Person to Contact in Case of Emergency
Name: _______________________________________ Relationship: _____________________
Phone:________________________________
- Does your doctor know you are participating in this exercise program? Y _____ N _____
- Do you currently participate in exercise regularly? Y ____ N _____
If yes please describe your exercise:_________________________________________
Number of days per week________ Amount of time________
- Do you have, or have you had any of the following (answer Yes or No to each):
| a. Difficulty with physical exercise | Y _____ N _____ |
| b. Advice from physician not to exercise | Y _____ N _____ |
| c. Recent surgery (last 6 months) | Y _____ N _____ |
| d. Pregnancy (now or within last 3 months) | Y _____ N _____ |
| e. Obesity (more than 20 lbs over ideal body weight) | Y _____ N _____ |
- Do you currently smoke? Y ____ N ____
If yes, # years _______ # cigarettes/day _______
- Do you have any other concern you desire to express prior to engaging in the Targeting Fitness Program? Y ____ N ____
If yes, please express________________________________________________________
__________________________________________________________________________
SIGNATURE _________________________________________DATE__________________
REVIEWED BY_______________________________________DATE__________________
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US Army Center for Health Promotion and Preventive Medicine.
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