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  2. 2005
  3. May
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  5. UniFit Screening Assessment
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* Name:
   
* Date of Birth
   
* Age
   
 
 


Family Medical History
 
 
Has any close relative brother, sister, mother, father, grandparents suffered from the following?
Yes No
* Stroke
* Heart Disease/operation
* Angina
* Heart Attack
* High Blood Pressure
* High Cholesterol
* Asthma/Lung disorder
* Bronchitis, emphysema
* Diabetes
* Sudden Death
 
 
 
 
 


Personal Medical History
 
 
Have you experienced any of the following conditions?
Yes No
* Rheumatic fever or Scarlet fever
* Heart Trouble
* High Blood Pressure
* Chest Pain/Angina
* Stroke
* Disease of the arteries of veins
* Undue shortness of breath with exercise
* Fainting of blackout
* Epilepsy
* Asthma
Yes No
* Hay Fever
* Anaemia
* Diabetes
* Thyroid disorder
* Joint problems
* Swerious accident or injury
* Surgical operation
* Lung disorder
* Any other serious illness you think needs to be known.
 
 
 
 
 


Personal Habits
 
 
 
Nil Irregular Everyday
* How often do you Drink Alcohol
 
 
 
 
 
 
 
 

Do you smoke?
 
Never smoked
 
Gave up
 
Yes

 
 
 
Now Smoke ____ cigerettes a day
   
 
 


Current Medication
 
 
Please name and give dosages of any medications that you are currently taking
Drug Dose Time Since Last Dose
 
 
 
 
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