Medical Questionnaire SCHEDULE B If you were asked to complete this form on paper, please download this copy for printing. DatePersonalName *FirstLastDate of BirthCell #Phone #Work #Email *AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePhysicianName *FirstLastPhoneAddressAddress Line 1CityState / Province / RegionMedical InformationPhysiotherapist NameCompanyTotal SessionsChiropractor NameCompanyTotal SessionsOsteopath NameCompanyTotal SessionsRegistered Massage Therapist NameCompanyTotal SessionsOccupational Therapist NameCompanyTotal SessionsAcupuncturist NameCompanyTotal SessionsKinesiologist NameCompanyTotal SessionsOtherCompanyTotal SessionsAdditional InformationPlease provide additional information regarding your reasons for seeing the above specialistsMedical History and Present Medical Condition Questionnaire NameFirstLastDateIn order for you to gain the most benefit from this program, we encourage you to answer all of the following questions. If you are uncomfortable with answering a particular question, feel free to leave it blank. Please explain all YES answers at the end of this questionnaire. Have you have ever had any of the following conditions? 1. Allergies 2. Loss of hearing 3. Asthma 4. Kidney disease 5. Prostatitis 6. Colitis 7. Hepatitis 8. Liver disease 9. Elevated liver enzyme test 10. Pancreatitis11. Ulcer 12. Heart attack 13. Heart murmur 14. Positive stress test 15. Heart valve abnormality 16. Angina 17. Heart failure 18. High cholesterol 19. High blood pressure 20. Arthritis/rheumatism 21. Loss of consciousness 22. Epilepsy 23. Convulsions/seizures 24. Stroke 25. Diabetes 26. Thyroid trouble 27. Anemia 28. Eczema 29. Cancer (including skin cancer) 30. Sleep apnea Do you currently have or have you recently had any of the following? EYES,EARS,NOSE, THROAT31 Difficulty with night vision 32. Change in vision 33. Blurred or double vision 34. Bleeding gums 35. Frequent nosebleeds 36. Frequent sinus trouble 37. Recent hoarseness 38. Ringing/buzzing ears 39. Earaches PULMONARY 40. Shortness of breath 41. Chronic or frequent cough 42. Brown/blood-tinged sputum 43. Chest tightness 44. Wheezing GENITO-URINARY 45. Bladder trouble 46. Blood in urine 47. Irregular vaginal bleeding 48. Currently pregnant 49. Difficulty starting/stopping urination50. Urinating 3 times per night 51. Frequent or painful urination 52. Problems with sexual function GASTROINTESTINAL53. Vomited blood 54. Persistent diarrhea 55. Persistent constipation 56. Frequent abdominal pain 57. Frequent nausea 58. Frequent indigestion/heartburn59. Black/bloody bowel movement60. Hemorrhoids 61. Trouble swallowing 62. Hernia CENTRAL NERVOUS SYSTEM63. Fainting spells 64. Recurrent dizziness 65. Frequent headaches 66. Tremors 67. Memory loss 68. Loss of coordination 69. Difficulty concentrating 70. Numbness/tingling extremities HEARTNASCULAR 71. Palpitation (irregular heartbeat)72. Pain or discomfort in chest 73. High cholesterol 74. Swelling of feet 75. Leg pain while walking 76. Painful varicose veins MUSCULOSKELETAL77. Back trouble/pain 78. Neck trouble/pain 79. Joint injury/pain/swelling 80. Carpal tunnel syndrome MISCELLANEOUS 81. Bleeding/bruising easily 82. Enlarged glands 83. Rashes 84. Unexplained lumps 85. Chronic fatigue 86. Night sweats 87. Undesired weight loss 88. Snoring 89. Difficulty sleeping 90. Low blood sugar ADDITIONAL HEALTH AND LIFESTYLE QUESTIONS D 91. Are you experiencing any stresses, mood problems, relationship difficulties, or substance-related problems for which you would like resource or referral information on a confidential basis? 92. Do you occasionally use or are you currently taking any prescription or over-the-counter medications? List name, dosage, and the reason the medication is used on the next page. 93. Have you had any surgical operations in the last 10 years? 94. Has anyone in your immediate family developed heart disease before the age of 601 95. Do any diseases run in your family? 96. Do you currently have a cold/cough, or have you had any in the last two weeks? 97. Have you ever been hospitalized? If yes, list date, length of stay, and reason on the next page. 98. Are you currently under a doctor's care? If yes, list what you are being treated for on the next page. 100. Have you had a change in the size or color of a mole, or a sore that would not heal in the past year? 101. Do you have any special concerns regarding your health that you would like to discuss with the doctor? 102. Are you a current cigarette smoker? 103. Are you an ex-smoker?104. Have you used chewing tobacco or smoked cigars/pipe in the last 15 years? Please answer the following questions honestly.How many packs of cigarettes do you smoke a day?How long have you been smoking? How many years did you smoke? How many packs a day? When did you quit? In one week I drink:Single Line TextSingle Line Text (copy)Single Line Text (copy)When were your most recent immunizations?TetanusFlu shot PneumovaxWhen were you most recent health maintenance screening tests?CholesterolResultsPSA (Prostate) Results MammogramResultsSigmoidoscopyResultsPap smear ResultsDescribe any hobbies or recreational activities that have exposed you to noise, chemicals, or dust: Please describe typical weekly exercise or physical activities including any exercise at work: My current diet could be best characterized as (check all that apply): Low-fatLow-carb High-proteinVegetarian VeganNo special dietPlease explain all YES answers here. List the question number, and add details.COMPREHENSIVE CLIENT INFORMATION SHEET fill in your approximate workout duration for each day (in minutes).MondayTuesdayWednesdayThursdayFridaySaturdaySundayPlease submit your current exercise regimen along with this form (type it up or write it out for us). If you are not currently exercising regularly, have you ever been on a consistent exercise plan (at least 3x per week)? YesNoIf you have exercised on a consistent basis previously, how long ago was this and how long did it last?PART 5: MEDICAL AND HEALTH INFORMATIONIf you have any diagnosed health problems, list the condition(s)If you are on any medications, please list themWhat additional therapies or interventions are being undertaken for the given health problem(s)?If you have any injuries, please list them.What additional therapies or interventions are being undertaken for the given injury(s)PART 6: LIFESTYLE INFORMATIONWhat do you do for a living? What is the activity level at your job?None (seated work only) Moderate (light activity such as walking) High (heavy labor, very active) Does your job involve shift work? YesNoIf you follow a more regular schedule, do you work days, afternoons or nights? Are you a primary caregiver for children, individuals with a disability, or an elder relative7 YesNoHow often do you travel? RarelyA few times a year A few times a month WeeklyPlease list the physical activities that you participate in outside of the gym and outside of work. Please fill out the following with your most normal daily schedule listing the time you wake up, work and have breaks, work out and go to sleep. ie. 8:00am - Wake UpExactly how much money do you spend on groceries per month (provide amounts from your last two grocery bills)?How many times per week do you shop for groceries?How many meals do you eat in restaurants and/or fast food places per week?Exactly how much money do you spend on supplements per month?If you have any known food allergies, please list them below. Are there any other foods to which you're particularly sensitive (i.e., which cause excessive gas, bloating, stuffiness, or congestion)? SUBJECTIVE RECOVERY MEASURESPlease rate each item from 0 to 5.Sleep Quality:(0 = Poor Sleep, 5 = Very Good Sleep) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)Tiredness:(0 = No Tiredness, 5 = Very Tired)Willingness to Train:(0 = No Willingness, 5 = Very Excited to Train) (copy) (copy)Appetite:(0 = No Appetite, 5 = Very Hungry) Please outline your goals below, from most important to least important.Par-Q and YouHas your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?YesNoDo you feel pain in your chest when you do physical activity? YesNoIn the past month, have you had chest pain when you were not doing physical activity? YesNoDo you lose your balance because of dizziness or do you ever lose consciousness? YesNoDo you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? YesNoIs your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? YesNoDo you know of any other reason why you should not do physical activity? YesNoIf you answered Yes to one or more questions Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. -You may be able to do any activity you want - as long as you start slowly and build up gradual. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. -Find out which community programs are safe and helpful for you. If you answered No to All questions: DELAY BECOMING MUCH MORE ACTIVE: if you are not feeling well because of a temporary illness such as a cold or a fever - wait until you feel better; or if you are or may be pregnant - talk to your doctor before you start becoming more active. If you answered NO honest to iill PAR-Q questions, you can be reasonably sure that you can: start becoming much more physically active - begin slowly and build up gradually. This is the safest and easiest way to go. take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active. PLEASE NOTE: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan. SignatureClear SignaturePhoneSubmit