Health History Form

Name(required)

Email(required)

Date(required)

Have you had a heart attack, stroke, heart surgery or chest pain? (required)

Yes No

Has your doctor said you have cardiovascular, pulmonary, metabolic or other significant disease?(required)

Yes No

Has you doctor said you have high blood pressure (>140/90)?(required)

Yes No

Do you experience dizziness or fainting spells with activity?(required)

Yes No

Are you currently pregnant or within six weeks postpartum?

Yes No

Are you currently taking medication for an underlying disorder?(required)

Yes No

Do you have an acute or chronic orthopedic health condition that your doctor thinks would affect your work with me, like bursitis, tendonitis, arthritis, disc bulge, fractures, neck or back pain?(required)

Yes No

Do you have a medical condition not listed here that would affect your work with me?(required)

Yes No

If you are a female, do you still menstruate?(required)

Yes No

Are you physically inactive?(required)

Yes No

Please list any medications you are currently taking, and for what. (required)

Please use this box to elaborate on any YES answers listed above.

Please tell me a little more about what you want to accomplish in our session.(required)

Mindful Adventure

Exploring Fitness & Strength for Functional Health

Health History Form