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

  • Date Format: MM slash DD slash YYYY
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  • 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.
  • Date Format: MM slash DD slash YYYY
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  • Date Format: MM slash DD slash YYYY
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  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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  • Family Health History

    Please indicate the number of blood relatives (mother, father, grandparents, brothers, sisters, children) who have had

  • Please answer the following questions as completely and honestly as possible

    GOALS:

  • Please describe your typical exercise routine

    If you don’t currently exercise or haven’t exercised in the past skip this section.

  • Nutritional Habits

    Please describe what you typically eat and drink for meals and snacks throughout your day.

  • 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.

  • 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.

  • Date Format: MM slash DD slash YYYY

“Don’t let what you cannot do interfere with what you can do.”

— John Wooden