Medical History Form 

Past History

Have you ever had?

Family History

Have you ever had?

Present Symptoms Review

Medications

Have you ever had?
Recently or currently taking

Risk factors

1.

Do you smoke?

How much per day 

How many years?

2.

Body Weight/Diet

Current Weight

Current weight - 1 year ago

Your weight At 21

3.

Do you engae in physical activity?

What type of physical Activity?

How often?

How much time per day do you exercise? 

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Discomfort of Shortness of Breath

4.

Health and Fitness (Wellness) 

How would you describe your current state of well being ?

Please indicate why you exercise?

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Did you participate in school sports?
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The undersigned swear that the above information is true and correct to the best of his/her knowledge and recognizes that this assessment is not the equivalent of a medical evaluation or diagnosis. 

Your Signature