Sprtzdud Fitness
Health/Lifestyle History Questionnaire
(please print or type)
Date:
General Information:
Your Name: Date of Birth:
Address: City: State: Zip:
Home Phone: Work Phone: Cell Phone:
Email Address:
Physician’s Name/Practice: Phone:
Emergency Contact Information:
Name: Relationship to you:
Home Phone: Work Phone: . Cell Phone:
Medications:
Are you currently taking any medically prescribed medications? YES / NO
If YES, please list:
Are you currently taking any self prescribed medications? YES / NO
If YES, please list:
Comments:
Health Information: Do you have, or had, any of the following:
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Heart Disease
Heart Attack
Heart Murmur
Aortic Stenosis
Angioplasty/Stents
Heart Surgery of any kind
Chest pain with exertion
Chest pain at rest
Rheumatic fever
Bronchitis
Asthma
Emphysema
Shortness of Breath
Dizziness/Fainting
Liver Disease
Kidney Disease
High Blood Pressure
Diabetes
Visual/Eye Problems
Osteoporosis
Fibromyalgia
Arthritis
Bone/Joint Problem
Surgery
Cancer
Emotional Disorders
Other:
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Sprtzdud Fitness
Notes/Comments:
Family Medical History: Has your Mother/Father/Siblings suffered from any of the following:
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Heart attack or surgery prior to age 55
Heart disease of any kind
Stroke
High Blood Pressure
Osteoporosis
High cholesterol
Diabetes
Cancer
Lung disease
Obesity
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Lifestyle:
YES NO
Do you smoke?
If yes, please describe:
Previously a smoker?
If yes, please describe:
Do you drink alcoholic beverages?
If yes, please describe:
Are you currently involved in an exercise program?
If yes, please describe:
If NO, any particular reason why?
Have you participated in an exercise program before?
If yes, where and how often:
If yes, what did you do?:
Do you participate in any sports or outside activities?
If yes, please describe:
Do you feel that your Family/Friends have a strong influence in your decision making?
If yes, please describe:
Do you eat regularly (i.e., breakfast, lunch, dinner)?
Please describe a typical day for:
a Weekday:
the Weekend:
Do you sleep regularly (6hrs or more)?
If NO, please explain:
Exercise and Fitness:
What types of exercise are you interested in? (please check all that apply)
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Walking
Jogging
Biking
Swimming
Aerobic Classes
Free Weights
Strength Machines
Stability Ball
Yoga
Pilates
Flexibility/Stretching
Exercise-Bands
Balance/Coordination
Muscle toning/building
Other:
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Sprtzdud Fitness
Health goals/expectations:
Please list what you would like to accomplish with your exercise program over the next year (i.e. fat loss, better posture, etc.) ranking in importance for each term:
Short Term Goals (< 3 months):
Medium Term Goals (3-6 months):
Long Term Goals (6-12 months):
What EXTERNAL barriers (your environment such as work, schedules, weather) would get in your way of achieving these goals:
What INTERNAL barriers (your perception, thoughts, and beliefs about exercise, such as I’m not coordinated, I will look funny exercising, etc.) would get in your way of achieving these goals:
What Do You Feelyou have been successful at? (ie, getting a college degree, keeping a clean house, driving a car, playing golf, being a good friend, ….)
Having been successful how did you go about achieving it?
Health and lifestyle commitments:
How many days per week do you realistically plan on exercising?
1 day; 2 days; 3 days; 4 days; 5 or more days
How much time will you be able to set aside for your workouts (not including travel, shower, etc.)?
30 min; 30-60 min; 60-90 min; >90 min;
What level of intensity do you plan to exercise at or think you should be exercising at?
½ asleep; comfortable; break a sweat; hard to talk while exercising; ‘till I drop
How often do you plan on eating a well-balanced and nutritional diet?
1-3 days a week; Weekdays only; Not on the weekend; As best I can
client expectations:
Why do want to work with a Personal Trainer?
What qualities do you think your Personal Trainer should have? (i.e., gender, good personality, a college degree, a good listener, a drill instructor, other?)
Any comments or questions?
Waiver of Liability
I, the undersigned, have answered this Health/Lifestyle History Questionnaire to the best of my ability and knowledge. ______(client initials)
I understand that my failure to do so may place me at risk of sustaining injury from my exercise program. ______(client initials)
I understand that prior to engaging in any exercise programming or physical activity I am required to obtain the consent of my primary care Physician. ______(client initials)
I understand that it is my responsibility to update and inform my Personal Trainer of any health changes that differ from this questionnaire. ______(client initials)
I, the undersigned, understand that to participate in Exercise Programming and/or Fitness Testing this information will be shared with my Personal Trainer. ______(client initials)
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