Health History

Date

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

In case of emergency, whom may we contact?

Relationship

Phone

Physician Name

Physician Phone

Physician Fax

Present/Past History

Have you had OR do you presently have any of the following conditions (check if yes).

Family History

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

Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes). In addition, please identify at what age the condition occurred.

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?

Yes
No

What is your present occupational position?

Name of Company

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?

Yes
No

If yes, briefly describe

Can you currently walk 4 miles briskly without fatigue?

Yes
No

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?

Yes
No

If yes, briefly describe

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

Follow Us x