Michael G’s Sports and Fitness Training LLC Health History Questionnaire
Name:_____________________________________Age:_________DOB_________________
Date:____________

Address:_____________________________________________________________________
Name:___________________________________________
Parent/Guardian Name(s):_________________________________

Phone:________________________

Emergency Contact: (name/number/relationship)_________________________________
						       _________________________________
Physician’s Name and
Phone Number:___________________________________________________________
Assess your health status by marking all true statements:
History
Currently, are you experiencing symptoms/concerns (check if yes):

General								Blood
Nervous System							_____ Bleeding Tendency
_____ Recent Weight Gain						_____ Anemia
_____ Dizziness
_____ Recent Weight Loss						Stomach
_____ Headaches							_____ Heartburn
_____ Fatigue								_____ Stomach Pain
_____ Muscle Spasms/Cramps					_____ Nausea
_____ Weakness							
_____ Fever								Muscles/Joints/Bones
								            _____ Muscle Tenderness
Nose									_____ 	Joint Pain
_____ Nosebleeds							_____ Muscle Weakness
Heartbeat								_____ Joint Swelling
_____ Dryness							_____Muscle Spasm/Cramp
									Heart and Lungs
Throat									_____ Sudden Changes in
_____ Frequent Sore Throats					_____ Shortness of Breath
_____ Difficulty Swallowing						_____ Irregular Heart Beat
_____ History of Strep Throat					_____ High Blood Pressure
					_____ Cough
_____ Wheezing
Symptoms
_____ You experience chest discomfort with exertion.
_____ You experience unreasonable breathlessness.
_____ You experience dizziness, fainting, or blackouts.
_____ You take heart medication.

Other health issues
_____ You have diabetes.
_____ You have asthma or other lung disease.
_____ You have burning or cramping sensation in your lower legs when walking short distances.
_____ You have musculoskeletal issues that limit your physical activity.

List medications you are currently taking including dosage (strength and amount per day) and how long you have been taking the medication.
______________________________________________________
Please list all allergies (food, medication, insects, etc.(
______________________________________________________
Have you had a tetanus shot?_____________, If yes, include date___________

List any surgeries you have had including the date(s) ____________________________________________________________________________
Have you had any specific injuries?
Describe:____________________________________________________________________
Is there any information you wish to share regarding your health status?

What time do you go to bed during the week?___________ How many hours of sleep do you get during the week?_________________

Have you been exposed to COVID-19 in the last 21 days?__________, if not, then have you had a COVID-19 test? If yes, please give the date of the test_______________

To the best of my knowledge, the information provided is accurate and true.

Signature:
__________________________________________________________Date:_____________

Signature: (if under 18 years of age) Parent/Guardian signature required
__________________________________________________________Date:_____________