Medical History Form

First name

Last name

Birthday

Month

Day

Year

Address

Email

Medical History:

Do you currently have any of the following conditions? (check all that apply)

Asthma

Heart Disease

Diabetes

High Blood Pressure

Seizures

Back/Neck Problems

Joint Issues

Osteoporosis

Stroke

Arthritis

Respiratory Issues

Cancer (current or history)

Other (please specify)

Are you currently taking any medications?

Yes

No

If yes, please list all medications you are taking

Do you have any allergies?

Yes

No

If yes, please list any known allergies

Have you ever had any surgeries or major injuries?

Yes

No

If yes, please describe

Do you experience any of the following symptoms regularly?

Chest pain or tightness

Shortness of breath

Dizziness or lightheadedness

Fainting

Nausea

Joint pain or swelling

Muscle weakness

Fatigue

Unexplained weight changes

Numbness or tingling

Frequent headaches

Other (please specify)

Do you have any current injuries or conditions that may affect your ability to safely perform physical activity?

Yes

No

If yes, please describe

Has your doctor advised you against physical activity?

Yes

No

If yes, please describe

Do you have a family history of the following conditions? (please check all that apply)

Heart Disease

Stroke

Diabetes

Cancer

High Blood Pressure

Kidney Disease

Osteoporosis

Mental Health Issues (e.g., depression, anxiety)

Other (please specify)

Do you smoke?

Yes

No

Do you consume alcohol

Yes

No

If yes, how often

Do you use any illicit drugs including performance enhancers

Yes

No

If yes, please specify

By checking this box I agree to not perform a session with my trainer under the influence of any illicit substances or under the influence of alcohol

Do you have any medical concerns that may affect your participation in training?

Yes

No

If yes, please specify

By signing below I acknowledge that all of the information given was fully truthful to the best of my knowledge and I give consent for DFit Training to store and use this information for my training.

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