Mobile Health and Fitness | San Diego Training and Physical Therapy

C) Known diseases and symptoms

Known Diseases

Do you have any personal history of coronary or atherosclerotic disease (stents, bypass, etc.)? Yes No

Do you have any personal history of metabolic disease (thyroid, renal (kidney), liver? Yes No

Suggestive Symptoms

Have you been diagnosed with or exhibited symptoms of any of the following conditions?

Angina
Rapid Heart Rate
Breathing Problems (night)
Cardiac Surgery
Abnormal EKG
Embolism
Aneurysm
Stroke

Shortness of Breath
Ankle Edema
Known Heart Murmur
Vascular Disease
Thrombophlebitis
Fixed Rate Pacemaker
Valve Disease
Anemia

Asthma
Dizziness or Fainting
Claudication
Respiratory Infections
Epilepsy
Internal Defibrillator
Emphysema

If you checked off any of the above conditions, please explain:

Please list any prescription medications that you are taking:

Please list any non-prescription medications that you are taking:

Do you have any other non-cardiac related conditions or diseases? Yes No

If yes, please explain:

Date of your last physical examination:

Would you be willing to provide us with a copy of the blood chemistry panel? Yes No

D) Injuries or Other Orthopedic Limitations

Check the areas that have been injured both recently and in the past:

Neck
Spine
Lower Back
Spinal Stenosis
Shoulder
Elbow

Wrist
Hip
Knee
Ankle
Nerve Damage

Arthritis
Bursitis
Osteoporosis
Degenerative Disc Disease
Other

If you do check, please specify "right or left" if appropriate, and explain:

Are you presently receiving physical therapy, chiropractic, or any other form of rehabilitative therapy? Yes No

May we contact your therapist? Yes No

Therapist name:

Phone:

Are you aware of any medical or other personal limitations not covered by this questionnaire, which would restrict your participation in a program of physical activity? Yes No

If yes, please specify:

E) Your Health and Exercise Interests

Weight Training
Running
Pilates
Golf
Competitive Sports

Massage Therapy
Walking
Cycling
Tennis
Physical Therapy

Nutritional Counseling
Yoga/Tai Chi/Meditation
Swimming
Stretching
Aquatic physical therapy

F) Health and Fitness Objectives

Please list your goals for this program:

Release of Liability Waiver

Because physical exercise can be strenuous and subject to risk of serious injury, we urge you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity. You agree that by participating in physical exercise, physical therapy or massage therapy activities, you do so entirely at your own risk. Additional recommendations for food supplements, or weight reduction products, are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes. You agree that you are voluntarily participating in these activities and assume all risks of injury, illness, or death.

You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a release of liability. You expressly agree to release and discharge the trainer or therapist from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer or therapist for personal injury or property damage.

If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.

By checking the box, I acknowledge that I have read and accepted the above agreement, I understand its content and that this release cannot be modified orally.

Cancellation Agreement

I retain Mobile Health & Fitness to render Personal Training, Physical Therapy, and/or Massage Therapy services.

I understand that I may cancel any appointment with my therapist by giving 24 hours’ notice. I also understand that if I fail to provide the aforementioned cancellation notice, as indicated, I will be charged for the full session fee.

By checking the box, I acknowledge that I have read and accepted the above agreement.

Health History Questionnaire

A) Client Demographics

B) Coronary Artery Disease (CAD) Risk Factors