Health and physical activity history

Name: ____________________________________________ Trainer: ________________________________ Address: __________________________________________ Age: ________ Birthdate: ________________ ___________________________________________________ Sex: ________ Height: ___________________ ___________________________________________________ Weight: ________________________________ Phone: Home (___)_________________________________ Business (___)___________________________ Physician’s Name: _________________________________ Phone: _________________________________ Address: ___________________________________________________________________________________ Emergency Contact-Name/Relationship:_________________________ Phone: _____________________ 1. Please check if applicable: CLIENT FAMILY IF YES, DESCRIBE ___ ___ ___ ___ _______________________________ ___ ___ ___ ___ _______________________________ ___ ___ ___ ___ _______________________________ Heart Attack ___ ___ ___ ___ _______________________________ Angina/Chest Pain ___ ___ ___ ___ _______________________________ Heart Murmur ___ ___ ___ ___ _______________________________ ___ ___ ___ ___ _______________________________ Abnormal Electrocardiogram ___ ___ ___ ___ _______________________________ Rheumatic Fever ___ ___ ___ ___ _______________________________ Thrombophlebitis ___ ___ ___ ___ _______________________________ Respiratory Infections ___ ___ ___ ___ _______________________________ ___ ___ ___ ___ _______________________________ Embolism ___ ___ ___ ___ _______________________________ Aneurysm ___ ___ ___ ___ _______________________________ Stroke ___ ___ ___ ___ _______________________________ ___ ___ ___ ___ _______________________________ ___ ___ ___ ___ _______________________________ 2. Do you have any of the following conditions that may limit your physical activity? (Please ___ Arm/Elbow Injury ___ Knee/Thigh Injury ___ Upper Back Injury ___ Head/Neck Injury If Other, please explain:_______________________________________________________ __________________________________________________________________________ 3. Has your physician ever advised you against exercise? If Yes, why? _____________________________________ ___________________________________________________________________________ 4. Are you presently receiving physical therapy? ___ Yes 5. Are you presently taking any medications? (Include over-the-counter medications.) If Yes, please list names and dosages of each: __________ __________________________________________________________________________ 6. Social History: ____Married _____Divorced _____Single Siblings #_______ Children # _____ Parents: Mother/Father: Living (age)_______________ Deceased (age) _____________ Do you use? Caffeine: _____ Type: ______ Amt. (cups) _________ Tobacco:______ # of yrs. _______ Amt/Day _________ Quit Date________ Alcohol: Beer(oz/wk)_____ Wine(oz/wk)______ Hard Liquor (oz/wk) ______ 7. Are you involved in an exercise program at the present time? ___ Yes If yes, please describe the program:______________________________________________ ___________________________________________________________________________ 8. How would you rate the amount of physical activity at work? 9. How would you rate the stress level of your job? 10. When exercising, including climbing stairs, do you ever experience any of the following? 11. Have you ever had a stress test? ___ Yes If so, date of most recent test:___________________ Results: ___ Normal ___ Abnormal 12. What was your weight one year ago? ______ Five years ago? _______ At age 20? _______ 13. Do you follow any special diet at the present time? If so, what type? ___ Low Cholesterol/Low Fat If Other, please specify: _______________________________________________________ 14. What are your personal exercise program goals? ___ Weight Control/Loss ___ Staying in Shape ___ Cardiovascular Conditioning ___ Other If Other, please specify:_______________________________________________________ 15. Which days and times are best for you? 16. What equipment do you presently have? ________________________________________ _________________________________________________________________________ 17. Any additional information or comments before beginning your exercise program? _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 18. T-shirt Size? SM _____ MED ______ LG ________ X-LG _______ XX-LG ________

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