Health History and Lifestyle Form

This form and the information you provide will be kept in a manner that assures your confidentiality. Any information you provide will be available only to your trainer and will be used solely in conjunction with planning and developing health and fitness programs. so your coach knows how to best help you!

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Question 1 of 33

Name

Paragraph answer

Question 2 of 33

Select all areas affected by the issues listed below. Nothing is too small or too old to matter. Use the diagram above for visual reference.

• Areas of acute or chronic pain

• Scars

• Tattoos

• Accidents

• Breaks/Sprains

• Dental Work

• Pregnancies

• Head Trauma

(Select all that apply)

A

Right Side of Face

B

Left Side of Face

C

Neck (front)

D

Clavicle (right)

E

Clavicle (left)

F

Ribs (right)

G

Ribs (left)

H

Abdomen (right)

I

Abdomen (left)

J

Right Hip

K

Left Hip

L

Groin

M

Bicep (right)

N

Forearm (front/right)

O

Right Hand (palm)

P

Bicep (left)

Q

Forearm (front/left)

R

Left Hand (palm)

S

Right Thigh (front)

T

Right Knee (front)

U

Right Shin

V

Right Ankle

W

Right Foot (top)

X

Left Thigh (front)

Y

Left Knee (front)

Z

Left Shin

AA

Left Ankle

AB

Left Foot (top)

AC

Left Side of Head

AD

Right Side of Head

AE

Back of Head (Left)

AF

Back of Head (right)

AG

Neck (back)

AH

Left Shoulder (back)

AI

Right Shoulder (back)

AJ

Upper Back (left)

AK

Upper Back (right)

AL

Low Back (left)

AM

Low Back (right)

AN

Left Glute

AO

Right Glute

AP

Tricep (left)

AQ

Forearm (back/left)

AR

Left Hand (back)

AS

Tricep (right)

AT

Forearm (back/right)

AU

Right Hand (back)

AV

Left Hamstring

AW

Left Knee (back)

AX

Left Calf

AY

Left Heel

AZ

Left Foot (bottom)

BA

Right Hamstring

BB

Right Knee (back)

BC

Right Calf

BD

Right Heel

BE

Right Foot (bottom)

Question 3 of 33

Please describe issues here.

(Ex. 2013, broke left hand and chronic aching, suture scars.)

Paragraph answer

Question 4 of 33

Do you wear corrective lenses? If so, please describe correction.

Paragraph answer

Question 5 of 33

Have you had corrective optical surgery? If so, please describe.

Paragraph answer

Question 6 of 33

Have you had any major life changes in the last 6-12 months?

Paragraph answer

Question 7 of 33

Please check those that apply.

(Select all that apply)

A

Shortness of Breath

B

Difficulty Focusing

C

Fatigue

D

PMS

E

Anxiety

F

Depression

G

PTS

H

Dizziness

I

Vertigo

J

Tinnitus

K

Headaches

L

Insomnia

M

Heart Disease

N

Blood Pressure

O

Chest Pain

P

Asthma / Lung Disease

Q

Thyroid Issue

R

High Cholesterol

S

Cancer

T

Allergies

U

Other

Question 8 of 33

If "Other," please describe.

Paragraph answer

FUEL AND SUPPLEMENTS

Question 10 of 33

Please list all medications that you are currently taking and their purpose/diagnosis.

(Include over the counter, prescription, and vitamin supplements.)

Paragraph answer

Question 11 of 33

Give me a bird's eye view on your current nutrition.

(What, when, how do you eat?)

Paragraph answer

Question 12 of 33

How would you describe your relationship with food?

Paragraph answer

EXERCISE

Question 14 of 33

What were your favorite activities as a child?

Paragraph answer

Question 15 of 33

What is your favorite physical activity today?

Paragraph answer

Question 16 of 33

What kind of strength, conditioning, or rehab exercises are you currently doing? (Detailed please!)

Paragraph answer

Question 17 of 33

What barriers do you feel you need to overcome in order to be as healthy and strong as you can be?

Paragraph answer

LIFESTYLE

Question 19 of 33

Profession and average work hours per week

Paragraph answer

Question 20 of 33

On average, how many hours do you sleep each night?

Paragraph answer

Question 21 of 33

What do you do to relax/reduce stress? How often do you do this?

Paragraph answer

Question 22 of 33

Do you/have you used tobacco?

A

Yes, I currently use tobacco.

B

Yes, I have used tobacco in the past.

C

No, I do not/have not used tobacco.

Question 23 of 33

How many alcoholic beverages do you consume per week, on average?

Paragraph answer

Question 24 of 33

How would you rate your stress level, overall? (With 0 being none and 10 extremely high.)

A

0 (none)

B

1

C

2

D

3

E

4

F

5

G

6

H

7

I

8

J

9

K

10 (extremely high)

GOALS AND BENCHMARKING

Question 26 of 33

PHYSICAL HEALTH

What are your current health and fitness goals?

Paragraph answer

Question 27 of 33

PHYSICAL HEALTH

How do you feel about your current progress toward those goals? (1 being not satisfied at all, 10 being completely satisfied.)

A

1 (Not satisfied at all)

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10 (completely satisfied)

Question 28 of 33

PHYSICAL HEALTH

What barriers - if any - are between you and your goals?

Paragraph answer

Question 29 of 33

PHYSICAL HEALTH

On a weekly or monthly basis, I'll know I'm on the right path if:

Paragraph answer

Question 30 of 33

Have you worked with a coach before? What worked for you? What didn't work for you?

Paragraph answer

Question 31 of 33

What would you like me to know that I haven't asked?

Paragraph answer

Question 32 of 33

I give my permission for my before/after photos and videos to be used in promotional materials.

A

Yes

B

No

Question 33 of 33

This form has been completed to the best of my knowledge and I will inform my coach of continuing health and lifestyle updates.

(Type your name.)

Paragraph answer

Confirm and Submit

Name

Email

Subscribe to our email list

Health History and Lifestyle Form

Click the button below to start.

Name

Select all areas affected by the issues listed below. Nothing is too small or too old to matter. Use the diagram above for visual reference. • Areas of acute or chronic pain • Scars • Tattoos • Accidents • Breaks/Sprains • Dental Work • Pregnancies • Head Trauma

Please describe issues here. (Ex. 2013, broke left hand and chronic aching, suture scars.)

Do you wear corrective lenses? If so, please describe correction.

Have you had corrective optical surgery? If so, please describe.

Have you had any major life changes in the last 6-12 months?

Please check those that apply.

If "Other," please describe.

FUEL AND SUPPLEMENTS

Please list all medications that you are currently taking and their purpose/diagnosis. (Include over the counter, prescription, and vitamin supplements.)

Give me a bird's eye view on your current nutrition. (What, when, how do you eat?)

How would you describe your relationship with food?

EXERCISE

What were your favorite activities as a child?

What is your favorite physical activity today?

What kind of strength, conditioning, or rehab exercises are you currently doing? (Detailed please!)

What barriers do you feel you need to overcome in order to be as healthy and strong as you can be?

LIFESTYLE

Profession and average work hours per week

On average, how many hours do you sleep each night?

What do you do to relax/reduce stress? How often do you do this?

Do you/have you used tobacco?

How many alcoholic beverages do you consume per week, on average?

How would you rate your stress level, overall? (With 0 being none and 10 extremely high.)

GOALS AND BENCHMARKING

PHYSICAL HEALTH What are your current health and fitness goals?

PHYSICAL HEALTH How do you feel about your current progress toward those goals? (1 being not satisfied at all, 10 being completely satisfied.)

PHYSICAL HEALTH What barriers - if any - are between you and your goals?

PHYSICAL HEALTH On a weekly or monthly basis, I'll know I'm on the right path if:

Have you worked with a coach before? What worked for you? What didn't work for you?

What would you like me to know that I haven't asked?

I give my permission for my before/after photos and videos to be used in promotional materials.

This form has been completed to the best of my knowledge and I will inform my coach of continuing health and lifestyle updates. (Type your name.)

Confirm and Submit

Select all areas affected by the issues listed below. Nothing is too small or too old to matter. Use the diagram above for visual reference.

• Areas of acute or chronic pain

• Scars

• Tattoos

• Accidents

• Breaks/Sprains

• Dental Work

• Pregnancies

• Head Trauma

Please describe issues here.

(Ex. 2013, broke left hand and chronic aching, suture scars.)

Please list all medications that you are currently taking and their purpose/diagnosis.

(Include over the counter, prescription, and vitamin supplements.)

Give me a bird's eye view on your current nutrition.

(What, when, how do you eat?)

PHYSICAL HEALTH

What are your current health and fitness goals?

PHYSICAL HEALTH

How do you feel about your current progress toward those goals? (1 being not satisfied at all, 10 being completely satisfied.)

PHYSICAL HEALTH

What barriers - if any - are between you and your goals?

PHYSICAL HEALTH

On a weekly or monthly basis, I'll know I'm on the right path if:

This form has been completed to the best of my knowledge and I will inform my coach of continuing health and lifestyle updates.

(Type your name.)