Client Health History
Personal Information
Tell me about yourself.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History and Conditions
Please indicate any conditions that apply to you.
Have you been diagnosed with any of the following conditions?
Heart Disease
High Blood Pressure
Diabetes
Asthma or Respiratory Issues
Arthritis
High Cholesterol
Thyroid Disorders
Other
Have you had any injuries or surgeries?
*
Yes
No
Please describe your injuries or surgeries (type, date, recovery status):
*
Are you currently taking any medications?
*
Yes
No
Please list your current medications and their purpose:
*
Are you currently taking any supplements?
*
Yes
No
Please list your current supplements and their purpose:
*
Fitness Goals and Experience
Tell us about your fitness background and what you hope to achieve.
What are your primary fitness goals? (Select all that apply)
*
Weight Loss
Muscle Gain
Increase Flexibility
Improve Cardiovascular Health
Sports Performance
General Health & Wellness
Other
How would you describe your current fitness level?
*
Beginner
Intermediate
Advanced
Describe your previous exercise experience (types of activities, frequency, duration):
Lifestyle
Help us understand your daily habits.
Do you get at least 7 hours of sleep per night?
*
Yes
No
Please describe your typical sleep pattern:
*
Do you experience high levels of stress?
*
Yes
No
Please describe your main sources of stress:
*
Would you like guidance on nutrition?
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Yes
No
Please describe your current eating habits:
*
Do you often feel low in energy?
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Yes
No
Please describe when you experience low energy and possible reasons:
*
Do you consume alcohol?
*
Yes
No
Please describe your alcohol consumption (frequency, amount):
*
Do you smoke or use tobacco products?
*
Yes
No
Please describe your tobacco use (type, frequency):
*
Signature
Please sign below to confirm that the information provided is accurate to the best of your knowledge.
Signature
*
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