HEALTH HISTORY QUESTIONNAIRE

Client's Name*

First NameLast Name

Name of Parent or Legal Guardian (if applicable)

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Confidentiality Notice

Your responses help tailor your coaching experience and mindbody performance plan. They are kept confidential and are not used for diagnosis or treatment. Life coaching is not psychotherapy and does not replace medical or mental-health care. If you have concerns about your mental or emotional health, please consult a qualified mental-health professional. By completing this section, you acknowledge personal responsibility for your own well-being during this program.

Please answer the following questions to the best of your ability. For the following questions, unless otherwise indicated, choose the single best choice for each question. All of your responses are completely confidential and may only be used in group summaries and/or reports. All information collected is subject to the Privacy Act of 1974. If you have any physical handicaps or limitations that would require special assistance with this questionnaire, please let your certified coach know. This form is in accordance with the American College of Sports Medicine guidelines for risk stratification when followed correctly by a certified professional.

Calm/contentGenerally balancedOften stressed or anxiousDepressed/low mod

YesNo

If yes, please specify.

YesNo

If yes, please list.

YesNo

If yes, type / frequency:

What are your most common sources of stress?

How do you typically cope with stress (e.g., exercise, meditation, avoidance, food, etc.)?

On a scale of 1–10, how effectively do you feel you manage stress?

Average hours of sleep per night

GoodFairPoor

YesNo

If yes, please specify:

YesNo

If “Yes,” please stop and reach out now to a licensed professional or call 988 (the Suicide & Crisis Lifeline in the U.S.).

I understand that life coaching focuses on personal development and behavioral change, not the diagnosis or treatment of mental illness. I take full responsibility for my physical, mental, and emotional health and agree to seek professional help if needed.

Please type your full name and the date

YesNo

DiabetesThyroidKidneyLiver Disease

YesNo

7. If you answered YES to any of questions 1 through 5, please describe:

8. Do you currently have any of the following:

YesNo

Have you discussed any of the above with your doctor?

YesNo

If yes, what is your expected due date?

YesNo

If yes, please list date and surgery/disease

YesNo

If yes, please list

YesNo

17. Describe your regular physical activity or exercise program:

Type

Frequency in days per week

Duration in minutes

Intensity

BMI

18. If you have answered YES to any of questions 7-16, please describe

YesNo

26. If you have answered YES to any of questions 18-24, please describe.

27. Please list below all prescription and over-the-counter medications you are currently taking:

Medicine / Dosage / Amount / Frequency

YesNo

If so, please list.

I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in the development of my fitness/wellness program and that it is my responsibility to contact a qualified professional about the suitability of fitness training and life coaching for my needs. If any of the above conditions change, I will immediately inform my Coach/Trainer of those changes. I understand that information regarding my medical or physical conditions is being collected for information purposes only. I knowingly and willingly assume all risks of injury resulting from training/coaching by Deborah Denova. Additionally, I knowingly and willingly assume all risks of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the attached questionnaire.

Client Signature*

Client's Full Name (Print)*

Parent or Legal Guardian Signature

Client's Parent or Legal Guardian Full Name (Print)*

If “Yes,” please stop and reach out now to a licensed professional or call 988 (the Suicide & Crisis Lifeline in the U.S.).

HEALTH HISTORY QUESTIONNAIRE

Mental Health History

Physical Health History