Medical History Questionnaire
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Phone Number
Email Address
Address
Emergency Contact
Name
Relationship
Phone Number
Medical History
Allergies
Current Medications
Past Illnesses or Hospitalizations
Past Surgeries
Chronic Conditions
Family Medical History
List any family medical conditions
Lifestyle
Do you smoke?
Yes
No
Former
Do you drink alcohol?
Yes
No
Describe your exercise routine
Other Comments
Please add any additional information