New Client Form & Health History Questionnaire
Date
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Month
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Day
Year
Date
Name
First Name
Last Name
Age:
Height
Weight
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Physician Name & Phone #
Emergency Contact Name & Phone #
Exercise
What exercise activities do you currently take part in (e.g., running, weightlifting, group exercise, etc.)?
How many days per week do you get at least 60 minutes of moderate-intensity exercise?
On a scale of 1-10 (1 low), how important are the following fitness goals to you?
1
2
3
4
5
6
7
8
9
10
Weight Loss
Muscle Gain
Sports Performance
Health Improvement
Flexibility
Mobility
Diet & Lifestyle
On a scale of 1 (poor)-10 (great), how would you rate the following?
1
2
3
4
5
6
7
8
9
10
Maintaining a healthy diet
Control over cravings for junk food
Average level of stress
Average amount of sleep each night
What techniques do you currently use to manage your stress levels?
Do you smoke tobacco or use a vaporizer alternative?
Yes
No
Are you currently following any kind of diet? If so, what diet and for what reason(s)?
How would you rank the following daily intakes:
Low
Medium
High
Very High
Salt
Sugar
Fat
Alcohol (weekly)
Occupation
What is your occupation?
Does your occupation require extended period of sitting? (If yes, please explain.)
Does your occupation require repetitive movements? (If yes, please explain.)
Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots)?
Recreation
Do you partake in any recreational physical activities (golf, skiing, etc.)? (If yes, please explain.)
Do you have any additional hobbies (gardening, fishing, crafts, etc.)? (If yes, please explain.)
Medical
Please list any past musculoskeletal injuries:
Please list any past surgeries:
If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity?
Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonary disorders, hypertension, diabetes, or cancer)? (If yes, please explain.)
Are you on any medications, and if so, have you received clearance from your doctor to take part in physical activity?
Additional Comments:
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