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.

Gender

Date of Birth

MonthDayYear

Age

years

Height

FT

Weight

LB

What do you do for a living?

What is the activity level at your job?

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

How often do you travel?

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

Do you have any health conditions?

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?

Are you experiencing any stresses or motivational problems?

if yes please list:

Has anyone of your immediate family developed heart disease before the age of 60?

Do any diseases run in your family?

if yes please list:

Do you suffer from diabetes, asthma, high or low blood pressure?

if yes please list:

Are you a current cigarette smoker?

Your current diet could be best characterized as:

Please rate your readiness for change. (1=Not ready, 10= extremely ready)

Which of the following goals best describe your goals?

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?

Please rate your motivational level to do what it takes for reach your goal. (1=Not motivated 10= extremely motivated)

Are you currently exercising regularly (at least 3x per week)?

Have you trained with a personal trainer before?

Have you trained with a nutrition coach before?

At what times during the day would you prefer to train?

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.

I AGREE TO THE ABOVE TERMS & CONDITIONS

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