HEALTH HISTORY--PERSONAL TRAINING

Name *

Name

First Name

Last Name

Email Address *

Mobile: *

Height

Age:

Birthday

Place of Birth

Current weight

Weight six months ago

Would you like your weight to be different?

If so what?

Relationship status

Where do you currently live?

Children:

Occupation:

Hours of work per week:

Please list your main health concerns:

Any pain stiffness or swelling?

Allergies or sensitivities? Please explain:

At what point in your life did you feel best?:Any

Any serious illnesses/hospitalizations/injuries?:

How is/was the health of your mother?

How is/was the health of your father?

How is your sleep?

How many hours?

Do you wake up at night? why?

Any healers, helpers or therapies with which you are involved?

What role do sports and exercise play in your life?:

Breakfast

Lunch

Dinner

snacks

Liquids:

Do you cook?:

What percentage of your food is home-cooked?:

The most important thing I should do to improve my health is:

Do you crave sugar, coffee, cigarettes, or have any major addictions?:

Anything else you would like to share?:

Favorite Cardio Exercise:

Least Favorite Exercise:

Have you ever worked with a trainer before: What did you like/dislike?

What did you like/dislike about your trainer?

What are your exercise goals?