Health History Form
  • Past and Present Personal Health History (check if applicable)Disease of the heartDiabetesAngina Pectoris (chest pain)EpilepsyAnemiaOrthopedic or muscular problemsCancerOther lung diseaseDiabetes MellitusStrokeHigh Blood PressureAsthmaAbnormal chest x-rayOther
  • If any of the previously mentioned conditions are checked, please explain further and indicate any recommendations your doctor has
    made regarding exercise.

  • Do you have a family history of heart disease, hypertension, stroke, diabetes, heart failure, lung disease or epilepsy?YesNoIf yes, please provide information regarding who the relative is, the medical problem, and the age at onset or death:
  • YesNoDo you currently smoke cigarettes? If yes, how many cigarettes per day?5-1010-2020+If in the past you quit, how long for?Less than 10 daysLess than a month3 months +
  • YesNoAre you currently taking medication prescribed by a physician? If yes, indicate name of medication, dosage taken,
    and the reason you are taking it:

  • Please indicate below any additional medical information that you think is important for us to know prior to fitness testing or exercise.
  • Do you currently take any nutritional supplements or follow any special diet (such as vegetarian, low calorie, etc.)?
  • Indicate the time you consume meals on an average day (including snacks) by printing the approximate time of consumption.
    Snack :8-10am10-12pm12-1pm
    Lunch :10-12pm12-2pm2-4pm
    Snack :12-2pm2-4pm4-6pm
    Dinner :2-4pm4-6pm6-8pm
    Snack :4-6pm6-8pm8-12pm

  • I think I am...(Pick one)Very underweightSomewhat underweightNormal weightSomewhat overweightVery overweight
  • How many hours do you work per week?
  • How do you spend most of your time at work? (Pick one)SittingWalkingDrivingStandingCarrying loadsOther
  • How many hours of sleep do you normally get?
  • Indicate how you are dealing with daily stress: (not coping well)12345(coping well)
  • Indicate your energy level: (not coping well)12345(coping well)

    I assume the risks involved in utilizing the Sports & Fitness facilities and programs including The Challenge. I also accept the sole
    responsibility for any injury that I may sustain by participating in Sports & Fitness and understand that Lively Group may in no way be held responsible. My signature on this form releases and holds harmless Lively Group and
    its components, including their Board of Regents, officers, employees, and personnel from
    any and all liability and claims relating to any possible injuries sustained as a result of my participation. Participation in this program
    and use of the facilities is at my own risk and completely voluntary.
    Print Name: Date:


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