Your Name: *


Subject: (please type in Health History)


Date of Birth (mm/dd/yyyy): *


Address:


City: *


State: *


Zip: *


Home Phone: *


Your Email: *


Work Phone:


Cell Phone:


Emergency Contact: *


Relationship to you: *


Emergency Phone: *


Doctor: *


Clinic: *


Clinic Phone: *


Height: *


Weight: *


Body Composition: *


Has your doctor ever said that you have a condition and that you should only do physical activitiy recommended by a doctor? *
Yes
No

Have you ever had a stroke or a heart attack? *
Yes
No

Do you feel pain in your chest when you do physically activity? *
Yes
No

In the past month, have you had chest pain when you were not doing physical activity? *
Yes
No

Do you ever lose your balance, feel faint, have dizzy spells, or lose consciousness? *
Yes
No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Yes
No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *
Yes
No

Have you had surgery in the last six months? *
Yes
No

Do you have diabetes, asthma or epilepsy? (If you have one of these conditions, please explain in the box, if not, leave blank)


Are you over the age of 69? *
Yes
No

If female, are you pregnant? *
Yes
No

Do you know of any other reasons why you should not do physical activity? *
Yes
No

Are you over the age of 55 if female, or the age of 45 if male? *
Yes
No

Has your doctor ever told you that you have high blood pressure *
Yes
No

Do you have high cholesterol (total >200 MG/D)? *
Yes
No

Do you have a family history of Heart Disease? *
Yes
No

Are you currently a smoker or have recently quit in the last 6 months? *
Yes
No

Do you currently or have you recently had any particular health concerns? (If yes, explain in the box, if no, leave blank)


Are you currently taking any medications? (please list name, dose and reason for medication, if no medications leave blank)


Please describe any past or present injuries and exercise-related pains: (If you have none, leave blank)


Are you currently undergoing treatment from a physical therapist, chiropractor, or massage therapist? (If yes, please explain, if no, leave blank)


Please describe your current exercise level: *


How would you rate your level of stress on a daily basis? *
Low
Moderate
High

Estimate how many hours of sleep you get each night: *


Are you currently following any type of special diet? (low or high calorie, low carb, cholesterol, salt, or fat, etc., if no, leave blank)


What do you think your ideal weight should be? *


Have you ever been your ideal weight in your adult years? If yes, how long ago? (If no, leave blank)


Please list your most important exercise goals: *


Are there any health or personal issues that may limit or prevent you from exercising? (If no, leave blank)