E-mail:
Age:
Relationship to College (please select one): Faculty Staff Spouse/Partner Graduate Student
Membership (please select one): Standard Membership Group Exercise Membership
If you currently have been diagnosed with cardiovascular, pulmonary, or metabolic disease (e.g. diabetes), it may exclude you from participation in the Ithaca College Wellness Program What activities do you do? Birthdate: Work Address: Phone: Home Address: Phone: Present Physician: Height: inches Weight: lbs Family History:Check if any blood relatives (parents, sister, siblings, etc.) had? Heart disease Stroke Diabetes High blood Pressure High Cholesterol Other conditions/comments: Medical/Health History: Check if you ever had? Heart disease/ Stroke High Blood Pressure Heart Murmur Skipped, rapid beats, or irregular rythms Rheumatic Fever Cancer Lung Disease Diabetes High Cholesterol Epilepsy Injuries to back, knees, or ankles Other conditions/comments: Present Symptoms: Have you recently had? Chest Pain Shortness of Breath Lightheadedness Heart Palpitations Loss of Consciousness Illness, surgery, or hospitalization Ankle/Leg swelling Joint/muscle pain Allergies (if yes please list under comments) Other conditions/comments:
What activities do you do?
Birthdate:
Work Address: Phone:
Home Address: Phone:
Present Physician:
Height: inches Weight: lbs
Family History:Check if any blood relatives (parents, sister, siblings, etc.) had?
Heart disease Stroke Diabetes High blood Pressure High Cholesterol
Other conditions/comments:
Medical/Health History: Check if you ever had? Heart disease/ Stroke High Blood Pressure Heart Murmur Skipped, rapid beats, or irregular rythms Rheumatic Fever Cancer Lung Disease Diabetes High Cholesterol Epilepsy Injuries to back, knees, or ankles Other conditions/comments:
Present Symptoms: Have you recently had?
Chest Pain Shortness of Breath Lightheadedness Heart Palpitations Loss of Consciousness Illness, surgery, or hospitalization Ankle/Leg swelling Joint/muscle pain Allergies (if yes please list under comments)
Please indicate if you currently have been diagnosed with cardiovascular, pulmonary, or metabolic disease (e.g. diabetes), as it may exclude you from participation in the Ithaca College Wellness Program Again, This may potentially exclude you from participation in our program
LIST ALL MEDICATIONS PRESENTLY TAKING: Health Habits: 1.SMOKING HISTORY: Do you smoke? Yes Quit Never What did (do) you smoke? Cigarettes Cigars Pipe How much did (do) you smoke a day? How long have you been smoking? If you've quit, when? 2. EXERCISE HABITS: Do you presently engage in physical activity? Yes No What kind?
How hard? Light Moderate Hard How often? Did your past exercise habits differ from what you are doing now? Yes No What kind of exercise did you do in the past?
How hard? Light Moderate Hard How often? How often are you planning on working out at the Wellness Clinic? Is your occupation- Sedentary Active Heavy work Explain your occupation
Do you have discomfort, shortness of breath, or pain with exercise? Yes No If yes, what type of exercise?
3.NUTRITIONAL BEHAVIOR: Do you consider yourself overweight? Yes No How long have you been overweight? How many meals do you typically eat per day? How often do you eat outside of the home? /week Do you presently consume alcohol? Yes No If yes, what? , number of drinks/week
4. STRESS: Do you consider your day stressful? Yes No What is the nature of your stress? How many hours do you sleep a night typically? Is your sleep sound? Yes No
ADDITIONAL PERTINENT INFORMATION:
GOALS FOR THIS SEMESTER: 1.2.3.4.5.
LIFETIME AND LONG TERM GOALS: 1.2.3.4.5.
SIGNATURE(simply type) DATE
Back to Home page