Health History - Energetic Parents NYC

212-879-1566 bonita@energeticparentsnyc.com

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Adult Health History

"*" indicates required fields

Name*

First Last

Gender*

Male

Female

Birthday*

MM slash DD slash YYYY

Age*

Address*

Street Address Address Line 2 City State ZIP Code

Occupation

Phone - Home or Cell*

Phone - Work

Email*

Emergency Contact Info

In case of emergency, please notify*

First Last

Emergency Contact Relationship*

Emergency Contact Phone*

Physician Name*

First Last

Physician Phone*

Medical Information

Are you under the care of a physician, chiropractor, or other health care professional for any reason?*

Yes

If yes, list reason:

Are you taking any medications?

Yes

If yes, list type, dosage/frequency, reason for taking:

High or low blood pressure?

Yes

Has your doctor ever told you that you have a bone or joint problem that has could be made worse by exercise?

Yes

Have you recently experienced any chest pain associated with either exercise or stress?*

Yes

Do you smoke?

Yes

Is there any reason not mentioned why you should not follow a regular exercise program?*

Yes

Please list any allergies:

Date*

MM slash DD slash YYYY

I acknowledge the above information to be true and accurate. To the best of my knowledge, I have given all relevant information regarding my health and ability to participate safely in an exercise program.**

Energetic Parents NYC

Adult Fitness Programs in NYC
Phone: (212) 879-1566
Email: bonita@energeticjuniors.com

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