Information – Health History – Digital Welcome Kit

Date:*

First Name:*

Last Name:*

Email:*

A copy of this form will be sent to this email address.

Phone:*

Date of Birth:*

Street Address:

City:

State /Province/Region:

Zip/Postal Code:

Have you ever retained a personal trainer or coach in the past?

Yes
No

If YES, approximate dates - Please describe your experience and if it met your expectations?

EMERGENCY CONTACT:

Contact:*

Phone:*

Relationship:

HEALTH HISTORY:

Did you receive a medical clearance from your physician prior to beginning your exercise program?*

Yes
No

Has your doctor ever advised you against exercise?*

Yes
No

If YES, please explain why.

Have you undergone any surgeries in the past year?*

Yes
No

If YES, please describe.

Do you have any areas of your body that limit you during exercise?

Yes
No

If YES, please describe.

Is this limitation constant or does it "come and go?"

It is constant
It comes and goes

What makes it better?

What makes it worse?

PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING:

Heart Problems
Chest Pain
High Blood Pressure
Asthma / Inhaler
Fainting

Hypoglycemia
Arthritis
Chronic Illness
Smoking
Muscle / Joint Problems

Neck / Back Injuries
Diabetes
Thyroid Conditiion
Pregnant
Breathing Problems
I HAVE NO MEDICAL CONDITIONS.

Other, not listed above. Please describe fully.

LONG TERM GOALS AND OBJECTIVES FOR YOU AND YOUR BODY:

Goal #1:

Goal #2:

Goal #3:

Goal #4:

Specific Body Areas: (ie; arms, legs, abs, glutes, etc.)

Specific Body Area #1:

Rank 1-10: (1 = "Not Happy" to 10 = "Happy")

Specific Body Area #2:

Rank 1-10: (1 = "Not Happy" to 10 = "Happy")

Specific Body Area #3:

Rank 1-10: (1 = "Not Happy" to 10 = "Happy")

Specific Body Area #4:

Rank 1-10: (1 = "Not Happy" to 10 = "Happy")

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