Health Assessment

First Name

Last Name

Address

Suburb

State

Post Code

Email

Phone Number

Private Health Insurance Private Health Insurance Yes No

Are you of Aboriginal or Torres Strait Islander Decent? Are you of Aboriginal or Torres Strait Islander Decent? Yes No

Who is your Doctor?

Practice Name

What is your reason for contacting iFitness?

MEDICAL CONDITIONS (tick all that apply) MEDICAL CONDITIONS (tick all that apply) High blood pressure High Cholesterol Cancer Heart Attack Diabetes Epilepsy Chest Pain Heart Disease Stroke Kidney Disease Blood Clots Osteoporosis Respiratory Disease Arthritis Heart Failure Other (give details below)

Please give details:

Do you have a family history of any of the conditions listed above? Do you have a family history of any of the conditions listed above? Yes No

Please give details:

HISTORY OF SYMPTOMS (tick all that apply) HISTORY OF SYMPTOMS (tick all that apply) Discomfort (eg. Burning, pressure, pain, tightness, numbness) in chest, jaw, neck, back, or arms Light Headedness, Dizziness, Fainting Temporary loss of vision or speech (including blurry vision) Weakness or numbness in one side of the body Unusual shortness of Breath Rapid heart beats or palpitations Swelling in the ankles or other joints

Are any of your symptoms brought on or aggravated by physical activity, temperature, stress, eating or other factor? Are any of your symptoms brought on or aggravated by physical activity, temperature, stress, eating or other factor? Yes No

Are you currently taking any regular medications? Are you currently taking any regular medications? Yes No

Please give details:

Are you currently a smoker? Are you currently a smoker? Yes No

Are you, or have you been pregnant in the last 12 months? Are you, or have you been pregnant in the last 12 months? Yes No

In the last 12 months have you had any illness or surgery or been hospitalized? In the last 12 months have you had any illness or surgery or been hospitalized? Yes No

Please give details:

Do you have any bone, muscle or joint problems? Do you have any bone, muscle or joint problems? Yes No

Please give details including any treatment you recieved:

Please list any physical activity you currently do:

Is there any other relevant medical condition or information not covered by the above questions that you feel may limit your ability to participate in physical activity and exercise testing? Is there any other relevant medical condition or information not covered by the above questions that you feel may limit your ability to participate in physical activity and exercise testing? Yes No

Please give details: