This is a copyright protected health history form designed to convert a standard medical history into a positive health guide. Use this health guide as a tool to focus your own thought processes so that you may better direct your own health care and fitness level. Condense your health concerns regarding your own body for better communication with healthcare professionals on a single page, if possible; if you have multiple medical situations, as many of us do, add additional paper, as necessary. Health (List top three health concerns) 1. 2. 3.
Physical Fitness (List top three fitness priorities) 1. 2. 3.
Life Performance (List top three accomplishment goals for your body) 1. 2. 3.
This includes activities in which you participate for sport, game, fitness and fun; this becomes important when we diminish healthful activities.
Fitness History childhood:___________________________None____ adolescence: ________________________ None____ adult: ______________________________ None____ (check, if applicable)
weight currently ________#, ideal_________ #
Attempts to change body weight up or down: This includes body building, fitness training, weight loss programs, gastric bypass, 12 step programs, anorexia, bulimia, steroid administration…
Environmental History List every location of residence or work since birth. If pertinent, also list pre-/perinatal health concerns for you ___________________________________________ _______________________________________________
Habits (please fill out to the best of your ability) Glasses, cc or ounces, of water per day: _________ Alcohol: glasses or bottles per day or week:______ Alcohol: Glasses or bottles per day or week ______
Smoke? Y N ? Quit Y N PPD: Then ______ Now_______ Stress: __________/10 during a typical day Stress: 6 months ago ____ /10 Now_________ During a typical day, rate your stress on a scale of 0-10 Zero: No physical or emotional discomfort Ten: the most physical or emotional pain that you can describe for yourself Meditate?: Y N Pain killers?: Y N name___________ Sleep: _________ hours per night Seat belt? Y N Car phone headset? Y N
Nutrition Meals per day:1 2 3 4 5 6
Portions per day of Protein (chicken, fish or red meat): ____________beans:___ nuts:___ Complex Carbohydrates (fruits/veggies): ____________ Simple Carbohydrates (bread, bagel, chips, popcorn):___________ bananas____ apples____ orange_____ melon_____ Fat (measure in TBSP/TSP) butter/oil_____ fried food # _____ peanut butter ____chips /cheese /milk / scones: _______ Please complete this form for your healthcare provider; This information is not helpful if it is not in your healthcare provider's hands and composed by you in your own words...