Health History

Date

First Name

Last Name

Street Address

Address Line 2

City

State / Province State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansansCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFlorida

ZIP / Postal Code

Country CountryAlabamaAlaskaAmerican SamoaArizonaArkansansCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFlorida

Email Address

In case of emergency, whom may we contact?

Relationship

Phone

Physician Name

Physician Phone

Physician Fax

Present/Past History Present/Past History Rheumatic fever Recent operation

Family History Family History Heart Attack Heart Operation Congenital heart disease High blood pressure High cholesterol Diabetes Other major illness

Explain the checked items above

Activity History

How were you referred to this program? (Please be specific)

Why are you enrolling in this program? (Please be specific)

Are you presently employed? Are you presently employed? Yes No

What is your present occupational position?

Name of Company

Have you ever worked with a personal trainer before? Have you ever worked with a personal trainer before? Yes No

Date of your last physical examination performed by a physician

Do you participate in a regular exercise program at this time? Do you participate in a regular exercise program at this time? Yes No

If yes, briefly describe

Can you currently walk 4 miles briskly without fatigue? Can you currently walk 4 miles briskly without fatigue? Yes No

Have you ever performed resistance training exercises in the past? Have you ever performed resistance training exercises in the past? Yes No

Do you have injuries (bone or muscle disabilities) that may interfere with exercising? Do you have injuries (bone or muscle disabilities) that may interfere with exercising? Yes No

If yes, briefly describe

Do you smoke? Do you smoke? Yes No

If yes, how much per day and what was your age when you started?

What is your body weight now?

What was your body weight one year ago?

What was your body weight at age 21?

Do you follow or have you recently followed any specific dietary intake plan, and in general how do you feel about your nutritional habits?

List the medications you are presently taking

List in order your 3 personal health and fitness objectives