Health History Profile

Name:

Date of Birth:   Age:

Work Phone:     

E-mail:     

Gender: M F

Past History
(Have you ever had?)

Heart Attack:  Yes    No

High Blood Pressure:  Yes    No

Any Heart Condition:  Yes    No

Stroke:  Yes    No

Epilepsy:  Yes    No

High Cholesterol:  Yes    No

Diabetes:  Yes    No

Rheumatic Fever:  Yes    No

Peripheral Vascular Disease:  Yes    No

Varicose Veins:  Yes    No

Abnormal Glucose Tolerance:  Yes    No

Respiratory Condition:  Yes    No

Asthma:  Yes    No

Allergies:  Yes    No

Surgery:  Yes    No

Back Injury:  Yes    No

Back Pain:  Yes    No

Heart Murmur:  Yes    No

Athletic Injuries:  Yes    No

Serious Infections:  Yes    No

Explain (in detail) if “yes” was checked

Please list and describe (in detail) any medications that you are currently on:

Family History
(immediate family only)

Heart Attack:  Yes    No

Stroke:  Yes    No

High Blood Pressure:  Yes    No

High Cholesterol:  Yes    No

High Triglycerides:  Yes    No

Diabetes:  Yes    No

Congenital Heart Disease:  Yes    No

Heart Surgery:  Yes    No

Obesity:  Yes    No

Present Symptoms

Chest Pain:  Yes    No

Pregnancy:  Yes    No

Heart Palpitations:  Yes    No

Cough on exertion:  Yes    No

Back pain:  Yes    No

Joint pain/swelling:  Yes    No

Arthritis/Bursitis:  Yes    No

Shortness of breath:  Yes    No

Insomnia:  Yes    No

Frequent Headache:  Yes    No

Upset Stomach:  Yes    No

Weakness of Fatigue:  Yes    No

Dizziness:  Yes    No

Other:  Yes    No

Explain (in detail) if “yes” was checked