What
race do you consider yourself to be? Select ONE of the following:
American Indian or Alaska Native.
A person having origins in any of the original peoples of North,
South, or Central America, and who maintains a tribal affiliation or
community attachment
Asian.
A person having origins in any of the original peoples of the Far
East, Southeast Asia, or the Indian subcontinent, including, for
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam. (Note: Individuals
from the Philippines Islands have been recorded as Pacific Islanders
in the previous data collection strategies.)
Black or African American.
A person having either origins in any of the black racial groups of
Africa. Terms such as "Haitian" or "Negro" can
be used in addition to "Black" or "African
American".
Hispanic or Latino. A
person of Mexican, Puerto Rican, South American, or other Spanish
culture or origin, regardless of race. The term "Spanish
origin" can be used in addition to "Hispanic or
Latino."
Native Hawaiian or Pacific Islander.
A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific islands.
White. A
person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.
Check here if you do not wish to disclose any or all
of the above information.
Primary Care Physician:
Name:
Office Phone:
Address:
Insurance Carrier:
Name:
Group No.:
ID No.:
Emergency Contact:
Name:
Relationship:
Phone #:
Medications:
include
over the counter drugs/oral contraceptives/dietary supplements
Name/Dosage/How often taken:
Allergies:
Smoking History:
Do you smoke?
Yes
No
Cigarettes?
Cigar?
Other?
If you quit, what
year did you quit
# packs per day for
# of years
Alcohol Consumption History:
Do you currently drink alcohol? Yes
No
If you drank alcohol
previously , when did you stop?
If you ever did drink alcohol, what is (was) the
volume consumed?
# ounces / day for:
# of years:
Exercise History:
Do you currently exercise aerobically?
Yes
No
How many years?
Duration:
Types of Exercise:
Frequency:
Do you compete in endurance events?
Yes
No
How many years?
Frequency:
What events?
If you are currently sedentary, when did you last
exercise?
Authorization to Release Information - Please check
one or both boxes and sign/date.
I authorize the Institute for Exercise and
Environmental Medicine to collect and save the above protected
health information on me for purposes of research. I understand that
all information is private and confidential.
I authorize the Institute for Exercise and
Environmental Medicine to keep this information and any information
gained from my participation in their studies in a database so that
they may contact me regarding future studies which may be a benefit
to me.
