Health History Form

Name

Age

Sex

Date of birth

Street address

City

State

Home Phone Number

Work Phone Number

Cell Phone Number

Email Address

Physicians name

Physician Phone Number

Emergency contact

Emergency Contact Phone Number

On average, how many times a week do you work out or participate in physical activity?

Answer here

Self History (check any that apply)

High blood pressure

Heart problems

Diabetes

Cancer

High cholesterol

Obesity

Smoking

Are you currently taking any medications that would affect your ability to exercise? (Please list)

List here

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

Answer

YesNo

Do you have a bone or joint problem that could be aggravated by physical activity? (Please describe)

Describe here

Do you suffer from back pain?

Explain

List three of your overall short term goals.

List short term goals here

List three of your overall long term goals.

List long term goals here

Would you participate in a program that would help you enhance your overall health?

Yes No

YesNo

If yes, which of the following Brushy Creek Community Center programs would you be interested in?

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

Yes or no

YesNo

If yes, please explain.

Explain here

First name

Last name

Date

Privacy Act

The District is obligated under the Texas Open Records Act to give out personal and private information on customers (such as name, address, telephone number, social security, etc.). Under the act this information is accessible to salesman, bill collectors, disgruntled spouses, telephone solicitors, junk mail listings or anyone else that may want to know about you and your account. If you DO NOT want any information given out regarding you or your account, please check the box below.

I (we) request that under the Privacy Act, the District not release any information.

Check Box

Although BCMUD water is discolored due to the early July Central Texas flooding events, it remains safe for all uses. Learn more here.

Health History Form

Privacy Act