Gym Health & Goal

Full name*

First Name Last Name

Birth Date*

Month Day Year

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

E-mail*

Phone Number*

Area Code Phone Number

Please read the questions carefully and answer each one honestly: check YES or NO or indicate how much.

Par-Q*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel fain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

Health History*

	Yes	No	Low	Medium	High
Occupational Stress Level?
Energy Level?
Caffeine
Alcohol
Smoke
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Thyroid Disorder
Depression/Anxiety
Gastrointestinal Disorder
Diabetes
Asthma/Respiratory/Pulmonary Conditions
Allergies (i.e. food, seasonal)
High Blood Pressure
High Cholesterol
Heart Attack
Heart Diease
Stroke
Gout

Pain History*

	never	sometimes	always	previous injured/current	had surgery
Head/Neck
Upper Back/ Traps
Shoulder/Clavicle
Arm
Elbow
Wrist
Hand
Lower Back
Spine/vertabrae
Hip/Pelvis
Knee
Calf
Ankle
Foot
Hernia
Abdominals

Are you on any specific food/diet plan? If yes, please list and include who prescribed it:

How would you describe your current nutritional behaviors? Please write any other food/nutrition issues you want to include: (food allergies, eating pattern i.e. fasting, keto, paleo, vegan, vegetarian etc)

Do you notice your weight fluctuating? Have you experienced a recent weight gain or loss? Over what amount of time? If yes, please explain:

Do you take dietary supplements? If yes, please list:

Date

MoisJour Année AM/PM Option

Nutrition Intake