Medical History/Health
Habit Questionnaire



Personal Information
Name:

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:



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


GOALS FOR THIS SEMESTER:



LIFETIME AND LONG TERM GOALS:



SIGNATURE(simply type) DATE


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