YL Fit & Wellness LLC – Health History Questionnaire
Please complete this form to help us understand your health background and accessibility needs.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
First Name
Middle Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Background
Physician Name
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Currently under medical supervision?
*
Yes
No
Medical Conditions
Surgeries or Hospitalizations
Current Medications or Supplements
Do you have any allergies?
*
Yes
No
Please specify your allergies
Are you currently pregnant or postpartum?
Yes
No
Prefer Not to Answer
Do you currently smoke or vape?
Yes
No
Physical Activity History
How often do you exercise?
*
Never
1–2 Times Per Week
3–4 Times Per Week
5+ Times Per Week
Current exercise or physical activities
Do you experience pain, tightness, discomfort, or limited movement during physical activity?
*
Yes
No
If yes, please describe the affected areas and type of discomfort
Fitness Goals
Accessibility & Communication Preferences
Requires Visual Instructions?
*
Yes
No
Preferred Communication Methods
*
Text Message
Email
App Messages
Video Call
ASL Video Communication
Other
Accessibility Accommodations
Electronic Signature
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: