DEMOGRAPHIC
First
Last Name
D.O.B.
(04/07/1973 )
Age
Height
(inches)
Address
City
State
Zip
Phone
(Home)
Phone
(Work)
Phone
(Cell)
Email Address
HEALTH HISTORY
Are you seeing a physician? (If so, please list reason)
Physician’s Name:
Physician’s Phone:
Are you taking any medications or drugs? (If so, please list medication, dose and reason)
Does your physician know you are
Yes
No
Have you ever had in the past, or currently have:
Yes
No
1. Increased blood pressure
2. Any chronic illness or condition
3. Difficulty with physical exercise
4. Advice from physician not to exercise
5. Recent surgery (within the last 12 months)
6. Pregnancy (now or within the last 3 months)
7. History of breathing or lung problems, Asthma
8. Muscle, joint, back disorder, or previous injury affecting you
9. Diabetes or thyroid condition
10. Cigarette smoking habit
11. Obesity (more than 20 percent over ideal body weight)
12. Increased blood cholesterol
13. History of heart problems in immediate family
14. Hernia, or condition that may be aggravated by lifting weights
Do you have any limitations to exercise? (If so, what are they)
What is your current exercise program?
CARDIOVASCULAR:
Days/wk
Minutes/day
Heart rate range
STRENGTH TRAINING:
Days/wk
Minutes/day
Heart rate range
STRETCHING:
Days/wk
Minutes/day
Type of stretching
How long have you been following this regimen? (days/week, months)
Have you had injuries due to exercise? (Please be specific about dates, recovery and how the injury occurred)
Describe your energy level on most days of the week. Does it vary little/often?
WEIGHT HISTORY
Weight
Goal Weight
Body
Goal
Weight History:
Most
Age
Least
Age
Do you feel that you have had or now have an eating disorder? (please describe)
STRESS
On a scale of 1 to 10 (ten being very high), what is your stress level
at Work
at Home
SLEEP PATTERNS:
Average hours per night
Is your sleep at night?
fitful
restful
undisturbed
Do you eat when depressed?
Yes
No
Do you eat when stressed?
Yes
No
Do you eat when bored?
Yes
No
EATING PATTERNS
Meals
Snacks
Largest Meal
Calories
% Protein
% Fat
% Carbs
GOALS AND OBJECTIVES
Short-term goals (the next 3 months)
1.
2.
3.
Long-term goals (the next 12 months)
1.
2.
3.
I HAVE QUESTIONS OR WANT INFORMATION ABOUT:
