The Get-A-Grip Club

Health Questionnaire

Personal Information

Name ______________________

Address ______________________

______________________

Email Address ______________________

Home Phone ______________________

Cell Phone ______________________

Date of Birth ______________________

Height ______________________

Age ______________________

Medical Information

Please fill in the information below:

¨ Yes ¨ No Are you under the care of a physician, chiropractor, or other health care professional for any reason? If Yes, list reason:

__________________________________________________________

__________________________________________________________

¨ Yes ¨ No Are you taking any medications? If yes, list medication(s):

__________________________________________________________

__________________________________________________________

¨ Yes ¨ No Do you have high blood pressure?

¨ Yes ¨ No Has your doctor ever told you that you have a bone or joint problem that could be made worse by exercise?

¨ Yes ¨ No Are you unaccustomed to vigorous exercise?

¨ Yes ¨ No Is there any reason not mentioned why you should not follow a regular exercise program? If yes, please explain:

__________________________________________________________

__________________________________________________________

Lifestyle and Dietary Factors

Please fill in the information below:

Occupational Stress Level ¨ Low ¨ Med ¨ High

Energy Level ¨ Low ¨ Med ¨ High

Caffeine Intake/Daily: ___________________

Colds per year: ___________________

Gastrointestinal Disorder: ¨ Yes ¨ No

Hypoglycemia: ¨ Yes ¨ No

Alcohol Intake/Weekly: ___________________

Anemia: ¨ Yes ¨ No

Thyroid Disorder: ¨ Yes ¨ No

Pre/Postnatal: ¨ Yes ¨ No

Cardiovascular Information

Please check if you have any of the following:

¨ High Blood Pressure

¨ Hypertension

¨ High Cholesterol

¨ Hyperlipidemia

¨ Heart Disease

¨ Heart Attach

¨ Angina

¨ Stroke

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:

¨ Head/Neck _______________________________________

¨ Upper Back _______________________________________

¨ Shoulder/Clavicle _______________________________________

¨ Arm/Elbow _______________________________________

¨ Wrist Hand _______________________________________

¨ Lower Back _______________________________________

¨ Hip/Pelvis _______________________________________

¨ Thigh/Knee _______________________________________

¨ Arthritis _______________________________________

¨ Hernia _______________________________________

¨ Surgeries _______________________________________

¨ Other: _______________________________________

Nutritional Information

¨ Yes ¨ No Are you on any specific food/diet plan at this time? If yes, please list:

__________________________________________________________

¨ Yes ¨ No Do you take dietary supplements? If yes, please list:

__________________________________________________________

¨ Yes ¨ No Do you experience frequent weight fluctuations? If yes, please list:

__________________________________________________________

¨ Yes ¨ No Have you experienced a recent weight gain or loss? If yes, please list:

__________________________________________________________

How would you describe your current nutritional habits?

¨ Good ¨ Fair ¨ Poor

How many meals do you eat per day including snacks?

__________________________________________________________

Other food/nutritional issues you want to include?

__________________________________________________________

Signature

NAME:__________________________________

SIGNATURE:_____________________________ DATE:______________

SIGNATURE OF PARENT:__________________

or GUARDIAN (for participants under the age of 18 years)