Welcome to Images:126 Fitness
Medical History Form:
Print document fill out and bring to the gym:
StayFit Medical History
Name_______________________ Date__________
Please answer all the questions to the best of your ability
1. Are you currently seeing any physician(s) for any conditions or regular check ups? If yes, please list the name of the physician(s) and the reason. ____________________________________________________________________________________________________________________________________
2. Are you currently on any medications or have you taken any medications in the past for any chronic conditions? If yes, please list name(s) and amounts taken._____________________
__________________________________________________________________
3. Do you smoke or have you smoked in the past? If yes, please note how much. __________________________________________________________________
4. Do you have high blood pressure or a past history of high blood pressure? ____
5. Do you have high cholesterol? ____
6. Have you ever had any type of heart condition? If yes, please describe the condition and what medical procedures have been taken to help the condition. __________________________
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7. Is there a history of heart conditions, high blood pressure, high cholesterol, or kidney disease in your family? If yes, please list. ____________________________________________
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8. Do you have asthma, any problems with breathing, or shortness of breath, especially while doing any kind of activity? If yes, please explain. ________________________________
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9. Do you have any conditions affecting your kidneys? If yes, please explain. ______________
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10. Do you have diabetes? If yes, please note whether type I or type II, and what medical care is being taken to control the condition. _________________________________________ __________________________________________________________________
11. If female, are you pregnant or planning to be pregnant within the next 3 months? ______
12. Do you have or have you ever had any stress fractures, broken bones, sprained joints, or strained muscles? If yes, please explain. ______________________________________
__________________________________________________________________
13. Do you ever have lower back or neck pain? If yes, please describe when and where at. ____________________________________________________________________________________________________________________________________
14. Have you ever or do you currently see a chiropractor? If yes, please explain the condition in which you have been or are currently being seen for. ______________________________
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15. Have you had rehabilitation for any orthopedic condition? If yes, please explain. _________
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16. Have you had any surgeries or are you planning to have any surgeries in the near future? If yes, please explain. ____________________________________________________
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17. Do you have any other conditions or diseases which were not mentioned previously? If yes, please list. _________________________________________________________
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I, ____________________________________, agree that I have answered all questions to the best of my knowledge and will inform the management of Stayfit Gym regarding any medical conditions not acknowledged at this time as soon as possible. I will also inform the management of Stayfit Gym in regards to any medical condition acquired while being a member at Stayfit Gym. I also agree that in the case of any medical condition, in which the management of Stayfit Gym requires a physician’s release prior to participation, I must acquire a verified release form from a physician and present it to the management at Stayfit before I will be allowed to participate in any activities. In any case that would require a physician’s release prior to participating at Stayfit Gym, I understand that my account will not be charged and any time loss will be redeemed to my contract. In the case where my physician will not release me to participate at Stayfit Gym; I understand that I will be refunded any fees paid upon my joining Stayfit Gym.
Print Name ________________________________ Sign Name ___________________________
Date _______________________
Legal Guardian (if under 18 yrs. old)
Print Name ________________________________ Sign Name ___________________________
Date __________________________
______________________________________________________________________
To Be Filled Out by Stayfit Management Only
Reviewed by ______________________________ Date ___________ Dr. Release Needed? Y N
Approved by ______________________________ Date ___________