Medical and Health History Form

Please complete this form accurately and honestly and bring to your appointment (allow 20 minutes to complete):

Date:
Name:
Address:

Phone: H:

W:

Mob:

Email:

Occupation:
Marital Status:

No. of Children (and ages):

Medicare Number:

Health Fund:

GPs Name, Address, Contact Number:

Specialists Name, Address, Contact Number:
*If you are having an online consultation, please provide your Skype name:


Section 1: Physical Activity Readiness Q

1.

Has your doctor ever said you have a heart condition and that you should only do
physical activity recommended by a doctor?

Yes No

2.

Do you feel pain in your chest when you do physical activity?

Yes No

3.

In the past month have you had chest pain when you were not doing physical
activity?

Yes No

4.

Do you lose balance because of dizziness or do you ever lose consciousness?

Yes No

5.

Do you have a bone or joint problem (for example, back, knee, or hip) that could be
made worse by a change in physical activity ?

Yes No

6.

Is your doctor currently prescribing drugs (for example, water pills) for blood
pressure or a heart condition?

Yes No

7.

Do you know of any other reason why you should not do physical activity?

Yes No

Dr. Bobby Cheema, PhD, AEP Clinical Exercise Physiologist www.drbobbycheema.com

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Medical and Health History Form

Section 2: Medical History

An accurate timeline of your medical history is important. Please include all diagnoses, traumas, highly stressful
periods, hospitalisations, surgeries and other major treatments. Attach additional pages if necessary.

0-5 years:
5-10 years:
10-20 years:
20-30 years:

30-40 years:

40-50 years:

50-60 years:

60-70+ years:

Section 3: Family History

Please list/describe all known diseases of the following family members, including physical and mental illnesses,
drug/alcohol addictions, and allergies

Mother:
Father:


Immediate Family Members (brothers, sisters, grandparents, aunts, uncles):






Dr. Bobby Cheema, PhD, AEP Clinical Exercise Physiologist www.drbobbycheema.com

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Medical and Health History Form

Section 4: Current Symptoms

Please list your current symptoms in order of severity. Symptoms include, for example, fatigue, muscle pain, joint
pain, nausea, dizziness, headaches, sleep disturbance (insomnia, etc.), excessive thirst/hunger, excessive sweating,
pale skin, feelings of excessive heat/cold, digestive issues (e.g. constipation, diarrhea). Attach additional pages if
necessary.

Symptom

Date first experienced

1.

2.

3.

4.

5.

6.

7.

8.

Section 5: Recent Medical Tests (in past 5 years):

Please provide details of any medical tests you have had in the past 5 years. Attach additional pages if necessary:

Type of Test

Date

Reason

Result

Blood test

X Ray

MRI

CT

Ultrasound
Vision
Hearing
Other

Dr. Bobby Cheema, PhD, AEP Clinical Exercise Physiologist www.drbobbycheema.com

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Medical and Health History Form

Section 6: Current Medications and Supplements

Please provide details of all the medications and supplements/herbal medicines you currently take.

Medication and Indication

Dosage

Date commenced

Dosage

Date commenced

Supplement / Herbal Medicine

Section 7: Current Health Status and Lifestyle

Are you pregnant?
Are you attempting to conceive?

Yes No N/A
Yes No

How would you rate your energy level, on average? (circle one) 0 1 2 3 4 5 6 7 8 9 10
No energy High energy
How would you rate your sleep quality? (circle one)

0 1 2 3 4 5 6 7 8 9 10
Very Poor Excellent

How many hours per night do you sleep, on average?

How many liters of water do you drink per day, on average?

Do you have filtered water at home?

Yes No

Do you drink alcohol? If so, how many standard drinks per day
or per week do you drink on average?

Yes No

_________ standard drinks per day

_________ standard drinks per week

Dr. Bobby Cheema, PhD, AEP Clinical Exercise Physiologist www.drbobbycheema.com

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Medical and Health History Form

Do you smoke cigarettes? If so, how many cigarettes do you

smoke per day on average


Do you drink coffee on a daily basis? If so, how many cups per
day

Do you take any illicit drugs? If so, please describe type and
usage:


Are you currently engaged in an exercise program? If yes,
please describe.

Have you previously performed any resistance training?

Do you have any favorite types of physical activities (sport,
recreation, leisure)? If yes, please list.

Yes No

_________ cigarettes per day

Yes No

_______ cups per day

Yes No

Describe:


Yes No

Describe:






Yes No

Yes No
Favorite activities:

Have you or are you currently playing competitive sport? If

yes, please describe.

Yes No

Do you want to improve your health status? If yes, please

describe some of the goals you have for yourself.

Yes No

Describe:

Goals:

Is there anything else you would like to mention?

Dr. Bobby Cheema, PhD, AEP Clinical Exercise Physiologist www.drbobbycheema.com

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Medical and Health History Form

Section 8: Dietary Schedule

Please provide an example of your dietary schedule for one typical week day (e.g. Monday-Thursday) and one typical
weekend day (e.g. Saturday/Sunday). List all meals, snacks and beverages (coffee, alcohol, soft drinks, juices etc.) for
the entire day and indicate which meals/snacks were prepared at home with an H and those purchased as packaged
food, restaurant/cafe food and take-away food as O (for out)

Time

Typical Weekday

Typical Weekend Day

5:00-7:00am

7:00-9:00am

9:00-11:00am

11:00am-1:00pm

1:00-3:00pm

3:00-5:00pm

5:00-7:00pm

7:00-9:00pm

9:00-11:00pm

11:00pm-1:00am

1:00pm-3:00pm

3:00am-5:00am

Thank you for detailing this important information about your medical and health history.

**Please bring this form with you to your appointment.**

Dr. Bobby Cheema, PhD, AEP Clinical Exercise Physiologist www.drbobbycheema.com

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