Health History Questionnaire

Congratulations!

You're on your way to discovering your amazing self and the marvelous things you are capable of.

Please fill out the following questionnaire to help Jennifer understand your current and past health concerns.

Name

Phone Number

Date of Birth

Emergency Contact Name

Emergency Contact Phone Number

Date of Last Physical

Please indicate any injuries you have had.

Please indicate any personal goals you have.

Are you currently pregnant or have you been in the last 18 months?

If recently pregnant, did you have a Casearian?

Please indicate if you have any allergies, including to medications.

Please list any operations/surgeries or hospitalizations you have had and the dates.

Please list any serious/chronic illnesses you have had.

Please list your current physical activities and note how long you have been participating in each activity

Please mark any medical conditions you or an immediate family member have had