FITNESS ASSESSMENT HEALTH HISTORY FORM

FITNESS ASSESSMENT HEALTH HISTORY FORM
Name:
Address:
Telephone:
Date of Birth:
Gender: Male Female
E-Mail:
Age:
Date:
General Instructions: Regular physical activity is safe for most people. However, some individuals should check
with their doctor before they start an exercise program. To help us determine if you should consult with your doctor
before starting to exercise with a Fitness Trainer, please read the following questions carefully and answer each one
honestly. All information will be kept confidential. Please check “YES” or “NO.”
YES
NO
1. Are you a male over 45 years of age
2. Are you a female over 55 years of age
3. Has anyone in your immediate family (parents/brothers/sisters) had a heart attack, stroke, or
cardiovascular disease before the age of 55 If YES, who:
4. Are you currently using tobacco products Cigarettes Cigars Chewing Tobacco
If YES, how long have you been using tobacco years How much per day
5. Have you quit using tobacco products If YES, how long ago did you quit years
6. Have you ever been told that you have high blood lipids or high cholesterol readings
7. Are you diabetic
8. Are you currently exercising LESS than one (1) hour per week If you answered NO, please
list your activities:
9. Has a physician ever told you or are you aware that you have high blood pressure
10. Do you have a history of heart problems or ever been told that you have a heart murmur
11. Do you feel pain of discomfort in your chest at rest or with exercise
12. Do you ever lose consciousness or have you ever lost control of your balance due to
dizziness
13. Do you ever experience unusual fatigue or shortness of breath with normal daily activities
14. Do you have any type of pulmonary or breathing problems such as asthma, emphysema, or
Chronic Obstructive Pulmonary Disease (COPD)
15. Have you ever had a stroke
16. Do you have epilepsy or have you ever had a seizure
17. Is there a family history of diabetes, high blood pressure, or cancer
18. Are you currently pregnant
19. Are you currently being treated for a bone or joint problem that restricts you from engaging in
physical activity
20. Have you had a medical physical from your personal physician If YES, months
21. Do you ever feel your heart race uncontrollably or “skip” a beat
22. Do you have any unusual shortness of breath at rest or with mild exertion
23. Are you currently taking any dietary supplements or medications If YES, please list the
name of the medication/supplement and the reason for taking it:

FITNESS ASSESSMENT HEALTH HISTORY FORM
Page 2
Are you an active firefighter and/or EMS provider Yes No
When was your last fire department physical/medical exam
Emergency Contact Name:
Relationship:
Telephone:
FITNESS TRAINER USE ONLY
Resting Heart Rate: I. II. III.
Resting Blood Pressure: I. II. III.
Weight: kg Target Exercise Heart Rate (85% MHR):
Cleared to Exercise NO YES
Date Physician Release Received:
• If client answered YES to two or more questions of the questionnaire.
• If first heart rate >110bpm and/or blood pressure > 160/100 mmHg, have client rest for five
(5) minutes and reassess. If unchanged, refer to physician and delay/reschedule assessment.
Signature:
Date:
Fitness Trainer (please print):
Fitness Trainer Signature: