top of page

HEALTH HISTORY QUESTIONNAIRE

Answer Each Question by Printing the Necessary Information. Your Answers are Confidential

MEDICAL INFORMATION _______________________________________________________________________

Are you under the care of a physician, chiropractor, or other health care professionals for any reason? if yes, list reasons:
Are you taking any medications? (if yes, complete the following- type, dosage/frequency, reason for taking):
Has your doctor said your blood pressure was too high?
Are you over the age of 65?
Is there any reason not mentioned why you should not follow a regular exercise program? If yes, please explain?
Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?
Are you unaccustomed to vigrous exercise?
Have you recently experienced any chest pain associated with either exercise or stress? If yes, please explain

FAMILY/ PERSONAL MEDICAL HISTORY _______________________________________________________

If there is family history for any condition, please check the box to the left. If you are personally experiencing any of these conditions, fill the information in on the line to the below. Required
Occupational stress level:

LIFESTYLE AND DIETARY FACTORS ____________________________

Energy level:

CARDIOVASCULAR _____________________________________________

MUSCULOSKELETAL INFORMATION ______________________________

Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort: If none put none or N/A

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

NUTRITIONAL INFORMATION ____________________________________________________________________

Do you take dietary supplements?
Have you experienced a recent weight gain or loss?
Do you experience any frequent weight fluctuations?
How many beverages do you consume per day that contain caffeine?
Other food/nutritional issues you want to include (food allergies, mealtimes, etc.)
How would you describe your current nutritional habits?

WORK AND EXERCISE HABITS ___________________________________________________________________

Please check the box that best describes your work and exercise Habits.
Do you work more than 40 hours a week?
To what degree do you perceive your WORK environment as stressful?
To what degree do you perceive your HOME environment as stressful?
Upload File
Upload supported file (Max 15MB)

Please feel free to upload any supporting photos or documentation.

Thanks for submitting!

FOLLOW US

  • Instagram
  • Facebook
  • YouTube

LEAVE US A REVIEW

Googlereview.png

HOURS OF OPERATION FOR GREENSBORO
BY APPOINTMENT ONLY

Monday-Friday 5:00 AM - 7:00 PM
Saturday 7:00 AM - 9:45 AM

*All days are by appointment only*

Coach DonnaKaye 336-345-3507
Office 336-482-8691

 

Medical Disclaimer
The information provided in or through this Website, including but not limited to, text, graphics, images and other material contained on this Website are for informational purposes only and solely as a self-help tool for your own use.  I am not, nor am I holding myself out to be a doctor/physician, nurse, physician's assistant, advanced practice nurse, or any other medical professional ("Medical Provider"), psychiatrist, psychologist, therapist, social worker ("Mental Health Provider"), or registered dietitian.  No material on this site is intended to be a substitute for professional medical advice, diagnosis, or treatment.  Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment before undertaking a new healthcare regimen.

Copyright © 2022 Esteem A Total Transformation by: Storkcreative

bottom of page