Health History Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

example@example.com

Phone Number*

Format: (000) 000-0000.

MaleFemale

Date of Birth*

MonthDayYear

Age*

years

Height*

FT

Weight*

LB

What do you do for a living?

None(seated only)Moderate (light activity such as walking)High (heavy labor, very active)

Do you follow a regular working schedule, do you work days, afternoon or nights?

RarelyA few times a yearA few times a monthWeekly

Please list the physical activities that you participate in outside of the gym and outside of work.:

YesNo

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

What additional therapies are being undertaken for the given health problem(s)?

If you have any injuries, please list them.

What additional therapies are being undertaken for the given injury?

YesNo

if yes please list:*

YesNo

if yes please list:

YesNo

if yes please list:

YesNo

What is your goal with your training/coaching?

Why?

Timeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train each week to reach your goal?

YesNo

MorningMid-DayAfternoonEvening

1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

4.) SOLICITATION

You are not allowed to solicit our coaches for any additional sessions, services or lessons. If this is violated, all sessions will be terminated. Our coaches are not allowed to solicit you directly for any additional sessions, services or lessons. If this is violated, all sessions will be terminated and another coach will be assigned.

5.) PRICING AND PAYMENTS

I understand that all pricing, payment and paperwork are not handled by the health coach.

6.) EXPIRATION

Sessions expire 120 days from the date of purchase.

7.) CANCELLATIONS/LATE ARRIVALS

As your health coach, if we are unable to keep an appointment for any reason and are unable to give you at least 24-hour notice, you will receive a free session. If you are unable to give us at least 24-hour notice of cancellation, we will count that as a session. Please be on time for your session - if you are late, the session must still finish on time. Thank you for your consideration.

YesNo

Signature*

Health History Form

Part 1. Basic information

Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Goals

Please Read The Following Terms and Conditions