Silver Strength Wellness

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About
Services
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Blog
Contact

Health History Form

Contact Information

Full Name

Date of birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address

Home Phone

Work Phone

Employer

Occupation

In case of emergency, please notify:

Relationship

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Home Phone or Cell Phone

Work Phone

Physician Information

Current Physician

Physician's Phone

Are you under the care of a physician, chiropractor, or other health care professional for any reason? If yes, list reasonYesNo

List reason you are under care

Are you taking any medications? (If yes, please list)YesNo

Medication | Dosage/Frequency | Condition:

List any and all allergies:

Has your doctor ever diagnosed you with high blood pressure?YesNo

Has your doctor ever diagnosed you with a bone or joint problem that has been or could be made worse by exercise?YesNo

Medical Information

Have you experienced any chest pain associated with either exercise or stress?YesNo

If yes, please explain:

Have you experienced shortness of breath with or without exercise?YesNo

If yes, please explain:

Have you experienced fainting or light-headedness?YesNo

If yes, please explain:

Have you had a recent hospitalization for any cause?YesNo

If yes, please explain:

Do you have any orthopedic conditions (including arthritis)?YesNo

If yes, please explain:

Have you ever experienced a rapid heartbeat or palpitations?YesNo

If yes, please explain:

Is there any reason why you should not follow a regular exercise program?YesNo

If yes, please explain:

Please indicate if a blood relative (parent, sibling, first cousin, etc.) has a history of any of the following conditions. If there is family history for any condition, please list below which family members have had the conditions and which conditions run in your family:

AsthmaRespiratory/Pulmonary ConditionsDiabetes: Type I – List how long belowDiabetes: Type II – List how long belowEpilepsy: List below – Petite Mal, Grand Mal, OtherOsteoporosisCoronary Artery DiseaseHeart AttackHypertensionHigh Blood PressureStrokeOther; Please list and explain below

List which family members have had the conditions and which conditions run in your family.

Please indicate if you (personally) have a history of any of the following dietary conditions; select all that apply:

AnemiaGastrointestinal DisorderHypoglycemiaThyroid DisorderPre/PostnatalOther; Please list and explain below

Please indicate if you (personally) have a history of the following cardiovascular conditions; select all that apply:

High Blood PressureHypertensionHigh CholesterolHyperlipidemiaHeart DiseaseSkipped HeartbeatHeart AttackStrokeBypass or Cardiac SurgeryAnginaGoutPhlebitis or EmbolismOther; Please list and explain below

Please list any other diagnosed conditions and the date of diagnoses:

Please indicate if you (personally) have a history of the following pain issues:

Head/NeckUpper BackShoulder/ClavicleArm/ElbowWrist/HandLower BackHip/PelvisThigh/KneeFeet/AnkleArthritisHerniaSurgeriesOther; Please list and explain below

Lifestyle/Habits

Do you smoke?YesNo

If yes, how often?Former user; List approximate quit date below1 or fewer cigarettes per day2 to 5 cigarettes per day6 to 10 cigarettes per dayMore than 10 cigarettes per day

Approximate date of quitting;

Do you drink caffeine?YesNo

If yes, how often:Several times a dayOnce per dayFew times per weekFew times per month

Do you drink alcohol?YesNo

If yes, how often:Several times a dayOnce per dayFew times per weekFew times per month

On average, how many hours of sleep do you get each night?More than 10 hours8-10 hours5-7 hoursLess than 5 hours

On average, what is your energy level like each day?High energyModerate energyLow energy

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