HEALTH HISTORY QUESTIONNAIRE | ESTEEM

Are you under the care of a physician, chiropractor, or other health care professionals for any reason? if yes, list reasons:

No

Yes

Are you taking any medications? (if yes, complete the following- type, dosage/frequency, reason for taking):

No

Yes

Has your doctor said your blood pressure was too high?

No

Yes

Are you over the age of 65?

No

Yes

Is there any reason not mentioned why you should not follow a regular exercise program? If yes, please explain?

No

Yes

Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?

No

Yes

Are you unaccustomed to vigrous exercise?

No

Yes

Have you recently experienced any chest pain associated with either exercise or stress? If yes, please explain

No

Yes

Occupational stress level:

Low

Medium

High

Energy level:

Low

Medium

High

Are you on any specific food/diet plan at this time?

No

Yes

Do you take dietary supplements?

No

Yes

Have you experienced a recent weight gain or loss?

No

Yes

Do you experience any frequent weight fluctuations?

No

Yes

How many beverages do you consume per day that contain caffeine?

No

Yes

Other food/nutritional issues you want to include (food allergies, mealtimes, etc.)

No

Yes

How would you describe your current nutritional habits?

No

Yes

Please check the box that best describes your work and exercise Habits.

Intense occupational and recreational exertion

Moderate occupational and recreational exertion

Sedentary occupational and intense recreational exertion

Sedentary occupational and moderate recreational exertion

Sedentary occupational and light recreational exertion

Complete lack of all exertion

Do you work more than 40 hours a week?

Yes

No

To what degree do you perceive your WORK environment as stressful?

Minimal

Moderate

Average

Extremely

To what degree do you perceive your HOME environment as stressful?

Minimal

Moderate

Average

Extremely