Health History

Health History / Lifestyle Questionnaire[1]

 

Name: __________________________________________                                                 Date: ______________

Age: ______    Email: _______________________________________

 

 

Yes

No

Do you smoke?

 

 

Do you drink alcohol?

 

 

Do you regularly exercise now? Yes-how often or No-when was the last time?

 

 

 

 

Are you tired or lack energy during the day?

 

 

Is your sleep consistent (same time and same amount) and restful?

 

 

Do you drink at least 8 glasses of water per day?

 

 

Do you drink coffee or soda?

 

 

Do you take prescription meds? What conditions are they prescribed for?

 

 

 

 

 

Do you take OTC meds? List.

 

 

 

 

Do you take herbal or nutritional supplements? List.

 

 

 

 

 

Do you take a multi-vitamin/mineral?

 

 

What do you eat in a typical week day (M-F)?

 

 

 

 

 

What do you eat in a typical weekend day (Sat/Sun)?

 

 

 

 

 

What is your occupation?

 

 

How stressful is your job?

 

 

Do you participate in any sports? Are they recreational or competitive? List.

 

 

 

Do you have back pain, knee pain or shoulder pain?

 

 

 

Do you have high blood pressure?

 

 

Do you have high cholesterol?

 

 

Are you epileptic or prone to seizures?

 

 

Do you have a cardiac condition? 

 

 

Do you have asthma?

 

 

Do you have diabetes?

 

 

Do you have stiff, swollen or painful joints?

 

 

 

Have you lost consciousness or fell over as a result of dizziness?

 

 

 

Do you suffer from depression?

 

 

 

Have you had any broken bones or joint injuries?

 

 

 

Have you had any surgeries?

 

 

 

Have you ever been told by a physician to avoid any type of exercise?

 

 

 

List any other health concerns or conditions that you have or have questions about.

 

 

 

 

 

 

What do you want to accomplish by training here?

Lose weight? Improve performance? Increase strength? Get healthy? Look great at the beach?

 

 

 

 

 

 

 

 

 

I accept that in order to accomplish my goals listed above, that it will require commitment and a huge effort on my part.

 

I understand that failing to train and eat properly will reduce my chances of success.

 

I, the undersigned, have read, understood, and have answered the above questions fully and truthfully. I am aware of my responsibilities to consult with my personal physician regarding my medical fitness to engage in exercise. I do hereby intend to be legally bound for myself and waive release of any and all rights and claims for damages I may have against the training facility and the fitness trainer/coach administering the exercise and/or nutritional program provided to me.

 

 

Name (print): ________________________________

 

Signature: ___________________________________                                              Date: _________________

 

 

 

 
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