HEALTH HISTORY QUESTIONARY

I. HAVE YOU HAD ANY SURGERIES ?

IF YES PLEASE DETAIL;
YES NO DOCTOR'S NAME, SURGERY NATURE, DATE, LIMITATIONS AND ETC:

II. DO YOU HAVE DIABETES? YES NO TYPE 1 CHECK THE BOX THAT PROPERLY DESCRIBLE

NO TYPE 2 THE DIABETES KIND.

III. DO YOU HAVE ANY OF THE FOLLOWING:

HABIT OF SMOKING
IF YES PLEASE DESCRIBLE HOW MANY CIGARRETS A DAY?
HOW LONG HAVE YOU HAD THIS SMOKING HABIT?
DO YOU INTEND TO CHANGE HABITS? YES

FAMILY HISTORY OF CARDIO VASCULAR DISEASE?

YES IF YES, PLEASE DESCRIBLE

HIGH BLOOD PREASSURE? YES HIGH CHOLESTEROL? YES

IV. PREGNANT?

YES HOW MANY MONTHS? MONTHS

V. ARE TAKING ANY MEDICATIONS?

YES IF YES PLEASE LIST AND PLEASE EXPLAIN WHY:

VI. DO YOU HAVE ANY CURRENT OR PAST INJURIES?

YES IF YES PLEASE LIST AND DETAIL:

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VII. DO YO HAVE ASTHMA OR ANY OTHER LUNG/RESPIRATORY ISSUES OR SYMPTOMS?

YES IF YES PLEASE LIST AND DETAIL:

VIII. DO YOU OFTEN FEEL SHORTNESS OF BREATH, FAINT, SUFFER FROM DIZZYNESS/LIGHTHEADNESS?

YES IF YES PLEASE DETAIL:

IX. DO YOU SUFFER FROM ANY JOINT PAIN OR ARTHRITIS, HEART PALPITATIONS?

YES IF YES PLEASE DETAIL:

X. DO YOU HAVE ANY ALLERGIES?

YES IF YES PLEASE LIST BELLOW:

XI. IS THERE ANY OTHER HEALTH ISSUE THAT HAS NOT BEEN MENTIONED ABOVE?

YES IF YES PLEASE LIST BELLOW:

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IGHTHEADNESS?