Medical History and Fitness Form

This form provides your medical and fitness history to the Exercise & Sports Science Center, powered by The Summit.

Name*

Date of Birth*

Contact Phone Number*

Medical History

Please check any of the following that apply.

Have you EVER been diagnosed with ANY of the following?

Heart Condition

Type

If you have been diagnosed with a heart condition, what type?

Cancer

Hypertension

Diabetes

Osteoporosis

Kidney Disease

Hepatitis

Neurological Disease

Arthritis

Pulmonary Disease/Asthma

Stomach Ulcer

Alcoholism/Drug Addiction

Depression

Thyroid Disease

Tuberculosis

Have you experienced ANY of the following in the past year?

Fallen This Year

Weight Loss/Gain

Difficulty Sleeping

Fatigue

Weakness

Fever/Chills/Sweating

Tremors

Seizures

Double Vision

Loss of Vision

Eye Redness

Nausea/Vomiting

Hearing Problems

Skin Rash

Excessive Stress

Numbness/Tingling

Joint/Muscle Swelling

Bruising Easily

Arm/Leg Swelling

Excessive Bleeding

Difficulty Breathing

Regular Cough

Heart Racing/Palpitations

Difficulty Swallowing

Heartburn/Indigestion

Constipation

Blood in Stools

Difficulty Urinating

Difficulty Holding Urine

Blood in Your Urine

Use a Walker or Cane

Do you have any known allergies?*

Please list any known allergies.

Please list ALL prescription medications/dosages and dietary supplements.*

If necessary, you can also attach a document with your list.

File Attachments

Drag and drop files here or

What are your PRIMARY Health, Fitness and/or Athletic Performance Goals/Objectives?*

Please describe in as much DETAIL as possible your current Exercise, Training, or Physical Activity Routine:*

Please provide an indication of Exercise Intensity [Highest heart rates achieved/observed during any exercise; cycling power outputs, average walking/running pace, recent race or event times 5K, 10K, 12K, ½ marathon, marathon]*

Please indicate your testing modality preference:*

Treadmill

Bicycle Ergometer

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