Health Status Questionnaire

HEALTH STATUS QUESTIONNAIRE
Prior to the start of any exercise program or testing a health fitness instructor must first administer
to their client a Health Status Questionnaire. This tool will aid the personal trainer in deciding
what course of action should be followed in regards to program recommendations.
Instructions
Complete each question as accurately as possible. All information is confidential.
Part 1. General information

1. Social security number__________-_______-__________Date_____________________
2. Name________________________________________ Nickname_________________
3. Mailing Address_______________________________ Phone (H)_________________
_______________________________ Phone (W)_________________
4. EI Personal Physician___________________________ Phone____________________
Physician Address_______________________________
_______________________________
5. EI Person to contact in case of emergency________________ Phone_____________
6. Gender (circle one): Female Male RF
7. RF Date of birth_______/________/________
8. Number of hours worked per week: Less than 20 20-40 41-60 over 60
9. SLA More than 25% of the time at your job is spent (circle all that apply)
Sitting at desk Lifting loads Standing Walking Driving
Part 2. Medical History
10. RF Circle any who died of heart attack before age 50:
Father Mother Brother Sister Grandparent
11. Date of
Last medical physical exam:______________
Last physical fitness test:_________________
12. Circle any operations that you have had:
Back SLA Heart MC Kidney SLA Eyes SLA Joint SLA Neck SLA
Ears SLA Hernia SLA Lung SLA Other________________________
13. Circle all medicine taken in last 6 months:
Blood thinner MC Epilepsy medication SEP Nitroglycerin MC
Diabetic SEP Heart rhythm medication MC Other______________
Digitalis MC High blood pressure medication MC
Diuretic MC Insulin MC
14. Please circle any of the following for which you have been diagnosed or treated by a
physician or health professional:

Alcoholism SEP Diabetes SEP Kidney problem MC
Anemia, sickle cell SEP Emphysema SEP Mental illness SEP
Anemia, other SEP Epilepsy SEP Neck strain SLA
Asthma SEP Eye problems SLA Obesity RF
Back strain SLA Gout SLA Phlebitis MC
Bleeding trait SEP Hearing loss SLA Rheumatoid arthritis SL
Bronchitis, chronic SEP Heart problems MC Stroke MC
Cancer SEP High blood pressure RF Thyroid problem SEP
Cirrhosis MC HIV SEP Ulcer SEP
Concussion MC Hypoglycemia SEP Other________
Congenital defect SEP Hyperlipidemia RF
15. Any of these health symptoms that occurs frequently requires medical attention. Circle the
number indicating how often you have each of the following:
5= Very often
4= Fairly often
3= Sometimes
2= Infrequently
1= Practically never
a. Cough up blood MC g. Swollen joints MC

1 2 3 4 5 1 2 3 4 5
b. Abdominal pain MC h. Feel faint MC
1 2 3 4 5 1 2 3 4 5
c. Low-back pain MC i. Dizziness MC
1 2 3 4 5 1 2 3 4 5
d. Leg Pain MC j. Breathlessness with slight exertion MC
1 2 3 4 5 1 2 3 4 5
e. Arm or shoulder pain MC k. Palpitation or fast heart beat MC
1 2 3 4 5 1 2 3 4 5
f. Chest pain RF MC l. Unusual fatigue with normal activity MC
1 2 3 4 5 1 2 3 4 5
Part 3. Health-related behaviors
16. RF Do you now smoke? Yes No

17. RF If you are a smoker, indicate the number smoked per day:
Cigarettes: 40 or more 20-39 10-19 1-9
Cigars or pipes only: 5 or more or any inhaled less than 5
18. RF Do you exercise regularly? Yes No
19. How many days a week do you accumulate 30 minutes of moderate activity?
0 1 2 3 4 5 6 7 days per week
20. How many days per week do you normally spend at least 20 minutes in vigorous exercise?
0 1 2 3 4 5 6 7 days per week
21. Can you walk 4 miles briskly without fatigue? Yes No
22. Can you jog 3 mile at a moderate pace without discomfort? Yes No
23. Weight now:___________lb. One year ago:__________ Age 21:__________
Part 4. Health-related attitudes

24. These are traits that have been associated with coronary-prone behavior. Circle the number
that corresponds to how you feel towards the following statement:
I am an impatient , time-conscious, hard-driving individual.
Circle the number that best describes how you feel:

6= strongly agree
5= Moderately agree
4= Slightly agree
3= Slightly disagree
2= Moderately disagree
1= Strongly disagree
25. List everything not included on this questionnaire that may cause you problems in a fitness
test or fitness program:
Code For Health Status Questionnaire
EI = Emergency Information-must be made readily available.

MC = Medical Clearance needed-do not allow to exercise without physician’s permission.
SEP = Special Emergency procedure needed-do not let participant exercise alone; make sure the
person’s exercise partner knows what to do in case of emergency.
RF = Risk factor for CHD (educational materials and workshops needed)
SLA = Special or Limited activities may be needed-you may want to include or exclude specific
exercises.
OTHER (not marked) = Personal information that may be helpful for files or research.

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HEALTH STATUS QUESTIONNAIRE

Complete each question as accurately as possible. All information is confidential.

Part 1. General information

physician or health professional:

a. Cough up blood MC g. Swollen joints MC

16. RF Do you now smoke? Yes No

Part 4. Health-related attitudes

Circle the number that best describes how you feel:

Code For Health Status Questionnaire

EI = Emergency Information-must be made readily available.

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