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Health History Questionnaire

Campus Recreation – Health & Fitness Program
A questionnaire for individuals aged 16 & above.

General Information:

Name: ______________________________ Date: __________ Telephone: ______________

Height: __________ Weight: ____________ Age: ___________ Sex: ____ M ____ F

Emergency Contact:
Name: ___________________ Relationship _________________ Telephone: ____________________

Physician’s Name: ________________________________ Telephone: _________________________

Risk Stratification:
Please check “yes” or “no” if you do, have, or have ever experienced any of the following conditions
Condition Yes No Year it began Comments
Ankle edema
Asthma
Breathlessness
Cardiac catheterization
Chest discomfort
Cigarette smoking
Diabetes
Dizziness, fainting, or blackouts
Less than 30mins of exercise, 3 day/week
Have a brother or father that had a heart attack
before the age of 55
Have a sister or mother that had a heart attack
before the age of 65
Heart attack
Heart disease
Heart failure
Heart surgery
Heart transplantation
High blood cholesterol
Hypertension
Leg cramps
Medications
Menopause
Numbness in limbs
Pacemaker
Pregnancy
Tachycardia
Take heart medication

*Note: Checking in 2 or more of the above criteria may result in a request of medical clearance prior to training.
This clearance can be faxed to 316-978-3071 or delivered to Andy Sykes 316-978-5287.
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If you indicated that you are currently taking medication, please list current prescriptions here :
Medication Dosage For What?

Please list any additional medical concerns/conditions that might limit your ability to participate in this program
(pregnancy, disability, etc.): ______________________________________________________
________________________________________________________________________

Please list any known allergies (environmental, medications, food, etc.):______________________________

_______________________________________________________________________________

Family Medical History:

I _____(initials), am voluntarily providing genetic and family history information to Campus Recreation in
connection with my participation in the voluntary wellness program offered by Wichita State University.
I understand that this information, if I choose to provide it, will be used only to assess my current health
and wellness, and make recommendations for improving my health and wellness in the future. Any genetic or
family history information that I provide to Campus Recreation will be shared only with me or with my licensed
health care provider. The information that I provide will not be shared with my employer in a way that would allow
the employer to recognize that the information is about me.
I do not have to provide any genetic or family history information to Campus Recreation. If I choose not to
provide this type of information, I am still free to participate in the program, with no reduction in incentives. By the
same token, I understand that I will not receive any “reward” or incentive to provide genetic or family history
information.

Please indicate if any family member has had any of the following*:
Medical Condition Relationship Age Comments
Cancer
Cardiovascular disease
Diabetes
Heart attack
High blood pressure
High cholesterol
Obesity
Osteoporosis
Stroke
Sudden death
*This information is helpful in assessing possible family history-related health risks.

Current exercise:
Are you currently engaging in physical activity: Yes ____ No ___
If yes, please give a brief description
________________________________________________________________________
________________________________________________________________________
__________________________

Please circle, on the scale of 1-10, how willing you are to make lifestyle changes that take
commitment (1=no desire; 10=very ready)

1 2 3 4 5 6 7 8 9 10
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Please read and initial the following:

____I certify that I have answered all health and fitness questions honestly and to the best of my ability.
____I understand the importance of providing complete accurate responses to allow my personal trainer to
personalize my workout sessions/regime.
____I recognize that my failure to do so could lead to possible unnecessary injury to myself during fitness testing
and/or exercise programs.
____I verify that if needed I will contact my doctor prior to becoming more physically active; as stated as a result of
my health questions/condition responses, and will provide a medical clearance from my doctor if necessary.
____I also understand my information will be kept in the personal training office locked file cabinet to keep it
secure and confidential
____ I will inform my personal trainer immediately of any changes that occur in my health status.

Waiver of Responsibility and Authorization of Use

I understand that sports, recreational activity or physical activity involve inherent risks of bodily injury and/or
physical harm, and I agree and acknowledge that I am fully informed of those risks and have been provided an
opportunity to ask questions and seek additional information. I am also fully aware of my current health and
physical condition.
In consideration of the opportunity to participate in a Campus Recreation program, as a Campus Recreation
member and/or guest, and with full and complete understanding of the consequences of my decision, I agree to
waive and release Wichita State University, its employees and its representatives, from any and all claims for
injuries and damages that may arise for and reason as a result of my participation in the Campus Recreation
program, including any and all claims based on the negligence of Wichita State University, its employees and/or
representatives
I grant permission to Wichita State University to use any photographs, motion pictures, recordings or any other
record of this event for publicity or other legitimate purpose as solely determined by Wichita State University.
I have read and fully understand and voluntarily accept the waiver of responsibility and provide the authorization of
use.

____________________________________ ___________________
Printed Name Date of Birth

____________________________________ ____________________
Signature Date

Please complete & turn in this Health History Questionnaire to the Guest Service Desk.
By completing this paperwork prior to the first session, will we determine if you need to seek physician approve
prior to starting an exercise routine. You should be contacted within the next 7 days by a Personal Training staff
member to set up your initial consultation and assessment session.

Training session prices and packages can be found in our Campus Recreation booklet and online at
www.wichita.edu/personaltraining

Thank you,

Rachel Hester
Health & Fitness Education Graduate Assistant
316-978-5278

Andy Sykes
Associate Director
[email protected]
316-978-5287
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Client Fitness Goals

Cell: ______________________________ Email: ___________________________

1. Current status (please check one):

__ Student __ Faculty/Staff __ Alumni __Student Spouse __ F/S Spouse __ Other

2. How did you learn about the Personal Training program?

__ Fitness & Wellness booklet __ Campus Recreation website __ Newspaper article

__ Student/spouse __ Referred by: ___________ __ Other: ____________

3. Days AND time ranges available to train: E.g.

Monday

a.m. 7-9
p.m. 6-8

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

a.m.
p.m.

4. Trainer preference: Male _____ Female _____ No preference _____

5. Fitness goals (check all that apply)

__ Increase strength __ Improve body shape __ Reduce body fat

__ Improve muscle tone __ Improve posture __ Improve athletic performance
__ Improve bone health __ Reduce stress __ Increase energy
__ Other (please explain): __________________________

6. How much time do you plan to devote to an exercise program?

On your own you can commit to: Want to meet with a personal trainer:

_______ days per week _______ days per week (maximum of 3)

_______ minutes per day (all Shocker Personal Training sessions

are 60 minutes in duration)

7. Are there any specific types of training that you would like to do?

8. Have you ever had a personal trainer before? What did you like or dislike about your experience?