Health History Form

Challenge yourself today

This Form and Your Confidentiality
This health history form is your opportunity to provide information that will assist our fitness coaches in evaluating your current level of health and fitness. Fitness Excellence^®, LLC will maintain this form and the information you provide in a manner that assures your confidentiality. Any information you provide will be available only to the fitness coaches of Fitness Excellence^®, LLC and will be used solely in conjunction with planning and developing health and fitness programs.
Basic Information
Name
Today's Date
Date Format: MM slash DD slash YYYY
Address
City
State
Zip Code
DOB
Date Format: MM slash DD slash YYYY
Age
Height
Weight
Mobile Phone
Home Phone
Email
Health History
Please indicate your history related to each of the following conditions by checking the appropriate box. If you have had any condition(s) in the past, please indicate the date in the appropriate space.
Heart murmur, clicks, or other cardiac findings
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Frequent extra, skipped, or rapid heart beats/palpitations
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Heart attack, coronary bypass, or other cardiac surgery
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Chest pain/angina (especially upon exertion
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Currently pregnant
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Diagnosed with high blood pressure
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Leg cramps during exercise
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Chronic swollen ankles
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Varicose veins
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Frequent dizziness/fainting
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Blood clot
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Severe arthritis
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Orthopedic problem(s) or complaint(s)
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Chronic back pain
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Musculoskeletal problems(s) or complaint(s)
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Asthma
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Cancer
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Diabetes
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Epilepsy
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Rheumatic Fever
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Scarlet Fever
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Bronchitis
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Stroke
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Pneumonia
- Never
- Now
Have Had(Date)
Date Format: MM slash DD slash YYYY
Recent Surgery (Please describe and give dates.)
Other medical problems/considerations, recent illness(es), hospitalizations(s), or injury
Current medications/prescriptions
Do you smoke?
- Yes
- No
Date of last complete medical or physical exam:
Do you know of any medical or health conditions, considerations, or circumstances that might make it dangerous or unwise for you to participate in an exercise program?
Family Health History
Please indicate the number of blood relatives (mother, father, grandparents, brothers, sisters, children) who have had
A heart attack prior to age 65
have had a stroke
have had or now have diabetes
have been or are substantially overweight
Please answer the following questions as completely and honestly as possible
GOALS:
1.
2.
3.
Please describe your typical exercise routine
If you don’t currently exercise or haven’t exercised in the past skip this section.
How many times per week?
How long per session?
What are your favorite types of exercise methods? (Ex: treadmill, bike, running, swimming, weights, types of machines)
Nutritional Habits
Please describe what you typically eat and drink for meals and snacks throughout your day.
Breakfast
Snack
Lunch
Snack
Dinner
Please tell us what you are looking for in a Fitness Coach.
Do you prefer male or female? Drill Sergeant or Subtle Supporter? In home, in a gym, outside, in person, on–line, etc.
If you are not sure what you are looking for in a Fitness Coach, but know you want someone to motivate you, educate you and tell you what you need to do to achieve your level of Fitness Excellence^® , leave this section blank.
Please tell us what you are looking for in a Fitness Coach
The information submitted on this Health History and Goals Form is true and complete to the best of my knowledge, and I understand that any wrong or incomplete information could result in a less effective fitness program, injury, or illness.
Print Name
Date
Date Format: MM slash DD slash YYYY
Signature
Signature of Parent or GUARDIAN (for participants under the age of 18)

“Character can not be developed in ease and quiet.
Only through the experience of trial and suffering can the soul be
strengthened, vision cleared, ambition aspired and success achieved.”

— Helen Keller

Health History Form

Challenge yourself today

This Form and Your Confidentiality

Basic Information

Health History

Family Health History

Please answer the following questions as completely and honestly as possible

Please describe your typical exercise routine

Nutritional Habits

Please tell us what you are looking for in a Fitness Coach.