Health History Questionnaire (HHQ) Health History Questionnaire (HHQ) Please complete as thoroughly as possible. We strongly encourage completing the form in the club so staff are available for questions. Depending on your risk factors checked on this questionnaire, guidelines from the American Heart Association and the American College of Sports Medicine may recommend physician clearance prior to exercise. If a physicians clearance is required, Four Seasons will contact your health care provider before prescribing an individualized exercise program. Please feel free to use the facility on your own. Type * Equipment Orientation Small Group Training Personal Training Pilates OtherOther Personal Information Name * Today's Date Date of Birth * Age Phone Evening Phone Physician Information Physician * Office Number Fax Number Section 1 Section 1 * Please check all that apply to you. Heart attack Chest Discomfort with exertion Heart surgery Experience unreasonable breathlessness Cardiac Catheterization Experience dizziness, fainting, blackouts Coronary Angioplasty Take heart medications Pacemaker/Implantable Defibrillator Currently pregnant Heart Valve Disease Musculoskeletal problems Heart Transplantation Chronic Obstructive Pulmonary Disease Congenital Heart Disease NOTHING IN SECTION 1 APPLIES Section 2 Section 2 * Please check all that apply to you. Male older than 45 years Cholesterol greater than 240 mg/dL Female older than 55 years or had a hysterectomy or postmenopausal Don’t know your total cholesterol Current smoker Your brother/father had a heart attack or stroke before age 55 and/or sister/mother had a heart attack before age 65 Blood pressure greater than 140/90 Diagnosed with diabetes or take medicine to control your blood sugar Don’t know your blood pressure Currently inactive ( less than 30 Minutes at least 3 days/week) Currently on blood pressure medication Currently 20 pounds overweight NOTHING IN SECTION 2 APPLIES Section 3 Section 3 Please check all that apply to you. Anemia Bleeding Disorder Cancer Carpel Tunnel Cerebral Palsy Chronic Fatigue Syndrome Clotting Disorder Crohn’s Disease Depression Eating Disorder Epilepsy Fibromyalgia Headaches/Migraines Heartburn Hepatitis HIV/Acquired Immune Deficiency Syndrome Irritable Bowel Joint Problems Kidney Stones Lymphedema Multiple Sclerosis Osteoarthritis Osteoporosis/Osteopenia Pulmonary Hypertension Rheumatoid Arthritis Sinusitis Systemic Lupus Erythematous Thyroid Disorder Ulcerative Colitis Ulcers OtherOther Section 4 Section 4 Please check all that apply to your personal goals Improve Flexibility Increase Tone of Muscles Increase Strength/Power Increase Muscular Size Improve Cardiovascular Ability Improve BP, Cholesterol, and/or Blood Glucose Levels Physician Recommended Improve Overall Health Decrease Stress Feel Better / Improve Energy Lose Weight, # of poundsLose Weight, # of pounds Gain Weight, # of poundsGain Weight, # of pounds Train for an event,Train for an event, OtherOther Section 5 Please list all prescribed or over the counter medications, herbs or supplements that you are currently taking including dosage and frequency. * Please enter 'N/A' if this does not apply Section 6 Current Height feet Current Height: inches inches Current Weight pounds Record numbers below if known: Blood Pressure Resting Heart Rate Total Cholesterol
