Covington Sportsplex Health History Questionnaire
Please complete the questions below.
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Date *
MM
/
DD
/
YYYY
Last Name, First Name *
Age *
Date of Birth *
Gender *
Phone Number (include area code) *
Have you ever had pains or a sensation of pressure in your chest that occurred with exertion, lasted a few minutes, and subsided with rest? *
Do you have any sudden bursts of very rapid heart action or irregular heartbeat without apparent cause? *
Do you have any known cardiac conditions that might prohibit an exercise program? *
Do you or any of your relatives have a history of heart disease? *
Have you ever had an abnormal electrocardiogram at rest or during exercise? *
Do you experience unusual breathlessness or exertion that is more than expected by others doing the same activity? *
Do you have arthritis, rheumatism, gout, or any condition affecting your joints? *
Are you a diabetic? *
Do you have any disk, sacroiliac, or back issues? *
Do you take any prescriptions on a regular basis? *
Do you have any allergies? *
Do you have any orthopedic problems affecting your feet, ankles, knees, or hips that cause pain or limit your range of motion in any way? *
Do you have asthma, emphysema, or any other respiratory conditions? *
Do you have any other medical conditions not mentioned? *
Do you currently smoke? *
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