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Personal Training Health History Form!
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PERSONAL! !
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3878 Wellington St., Mitchell, ON!
www.livewell4lifeinc.com!
[email protected]!
519-348-4600
Today’s Date: ___________________!
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Full Name:
Date of Birth (mm/dd/yyyy):
Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone:
Work Phone:
Email address:
Occupation:
☐Male
Hours worked per week:
☐Female
☐Married
☐Single
# of Kids & Ages:
How did you hear about LiveWell4Life Inc.?: !
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EMERGENCY CONTACT!
Name:!
Relation:
Address:
City:
Province:
Postal Code:
Phone:!
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OPTIONAL & CONFIDENTIAL
Age: __________
Height: __________
Weight: __________
How long at current weight?: __________
Goal weight: __________
1
3878 Wellington St., Mitchell, ON!
www.livewell4lifeinc.com!
[email protected]!
519-348-4600
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Trainer’s Notes:!
Please check any boxes that apply (past and current):
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_______________________________________________________________________________________________________________________________________!
Muscles/Joints/Nerves!
☐ Headaches(migraine/tension/
other)!
☐ Neck pain/injury/whiplash!
☐ Arm pain/weakness.tingling!
☐ Tooth/jaw/ear paint/TMJ!
☐ Back pain/injury!
☐ Sciatica/hip pain!
☐ Scoliosis/spinal curvature !
☐ Leg pain/weakness/tingling!
☐ Poor posture!
☐ Sports injury!
☐ Work-related injury!
☐ Vision problems/dizziness!
☐ Head trauma/concussion!
☐ Loss of co-ordination!
☐ Sleep problems/disorder!
☐ Muscle/nerve disease!
☐ Strain/sprain!
☐ Tendonitis/Bursitis !
☐ Fractures/bone disease!
☐ Degenerating disc!
☐ Osteo/Rheumatoid arthritis!
☐ Osteoporosis!
☐ Fibromyalgia!
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Skin!
☐ Open sore/cuts/warts!
☐ Rashes/athlete’s foot!
☐ Allergies (skin irritation)!
☐ Other (infectious): ____________!
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Heart/Circulation!
☐ High blood pressure!
☐ Low blood pressure!
☐ Heart attack/disease/stroke!
☐ Chest pain/angina!
☐ Blood clots!
☐ Pace maker/similar device!
☐ Varicose veins/phlebitis!
☐ Poor healing/bruise easily!
☐ Poor circulation!
☐ Cold hands and feet!
☐ Light headed/fatigue!
☐ Swelling!
☐ Diabetes: Type ____________
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Lungs/Respiration!
☐ Asthma/bronchitis/emphysema!
☐ Chronic smoking/cough!
☐ Frequent colds!
☐ Seasonal allergies/sinus problems!
☐ Shortness of breath!
☐ Sinus problems!
☐ Other: ____________!
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Digestion Constipation/diarrhea!
☐ Nausea!
☐ Rapid weight loss!
☐ Ulcers!
☐ Liver/gallbladder issues!
☐ Other: ____________!
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Genitourinary!
☐ Painful urination!
☐ Unusual urine colour/odour!
☐ Bladder/kidney infection!
☐ Prostate problems!
☐ Other: ____________!
_______________________________________________________________________________________________________________________________________!
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Other Conditions!
☐ Hepatitis: Type ____________!
☐ HIV infection!
☐ Multiple Sclerosis!
☐ Cancer!
☐ Epilepsy!
☐ Tuberculosis!
☐ Drug/alcohol addiction!
☐ Nicotine/caffeine addictions!
☐ Other: ____________!
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Are you pregnant?
☐YES
☐NO!
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If yes, how many weeks? _________!
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Any complications? ______________
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Rate your general health:!
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☐Poor
☐Good
☐Excellent
Please elaborate on any of the above conditions, or others that were not listed:!
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2
3878 Wellington St., Mitchell, ON!
www.livewell4lifeinc.com!
[email protected]!
519-348-4600
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Personal Training Questionnaire
Trainer’s Notes:!
Please list any medications including herbal supplements/vitamins and
over the counter drugs:!
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Please list any allergies:!
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Are you currently experiencing pain during daily activity? Explain: !
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Describe your current level of stress?!
_______________________________________________________________________________________________________________________________________!
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Please check yes or no for the following questions:!
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Do you smoke?!
☐Y ☐N!
Do you drink occasionally?!
☐Y ☐N!
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Have you been a member of a club/gym before?!
☐Y ☐N!
If yes, explain how often and how much: ______________
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Have you been exercising regularly for the past 6 months?! ☐Y ☐N!
If yes, please list: ________________________________!
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Have you ever worked with a trainer before?!
☐Y ☐N
If yes, explain: ___________________________________!
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☐Y ☐N!
Do you own any exercise equipment at home?!
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Please rate the following on a scale of 1 to 5 (1 being poor, 5 being excellent):
1) Present cardiovascular level !
1!
2!
3!
4!
5!
2) Present muscular level!
1!
2!
3!
4!
5!
3) Present flexibility level !
1!
2!
3!
4!
5!
4) Overall health
1!
2!
3!
4!
5!
5) Nutrition knowledge !
1!
2!
3!
4!
5!
6) Eating healthy !
1!
2!
3!
4!
5!
7) General knowledge of fitness exercises
1
2
3
4
5
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3
3878 Wellington St., Mitchell, ON!
www.livewell4lifeinc.com!
[email protected]!
519-348-4600
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EXERCISE PREFERENCES!
Please fill out the chart below based on current, past, and future fitness activities:!
On a scale of 1 - 5 (1=low, 5=high) rate your past to current level of
exercise/activity during each age range through to your present age range:!
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Trainer’s Notes:!
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13-20 years!
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1
2
3
4
5!
21-30 years!
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1
2
3
4
5!
31-50 years!
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1
2
3
4
5!
41-50 years!
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1
2
3
4
5!
51-60 years!
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1
2
3
4
5!
61-70 years!
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1
2
3
4
5!
70+ years!
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1
2
3
4
5!
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What interests, hobbies, and leisure activities do you enjoy?:!
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What types of exercise interests you?: !
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☐Traditional (machines or commonly used exercises)!
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☐Progressive forms of exercise (functional type training - using own body
weight and free weights)!
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☐Hybrid training (a combination of traditional and progressive)
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GENERAL!
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Does your occupation require extended periods of sitting?!
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Does your occupation require repetitive work? !
If yes, explain: __________________________________
______________________________________________!
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Does your occupation require you to wear dress shoes
with heels? !
Does your occupation cause you anxiety or stress?!
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☐Y
☐Y
☐Y
☐Y
Are you currently receiving care from another health care
professional (massage therapist, chiropractor,
physiotherapist, etc.)? !
If yes, who/what and what is your progress?: __________
______________________________________________!
______________________________________________
☐Y
3878 Wellington St., Mitchell, ON!
www.livewell4lifeinc.com!
[email protected]!
519-348-4600
Trainer’s Notes:!
☐N!
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☐N!
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☐N!
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☐N!
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☐N
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Do you have a preference of Personal Trainer? (If not, we will assign
trainer based on information and goals) !
☐Male!
☐Female!
☐Please recommend someone !
Name of preferred Trainer: _____________________!
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What is your favourite music to exercise to?: _____________________!
Would you characterize your life as:
☐Highly stressful !
☐Moderately stressful !
☐Low in stress!
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Are there any mottos or statements that you use for positive
reinforcement? Please list: ___________________________________!
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Do you consider yourself:!
☐Sedentary !
☐Lightly active!
☐Moderately active!
☐Highly active!
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Please describe some of your typical meals below: !
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Breakfast: !
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Lunch: !
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Supper:!
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Snacks:
5
3878 Wellington St., Mitchell, ON!
www.livewell4lifeinc.com!
[email protected]!
519-348-4600
GOALS!
Which of the following lifestyle, health, and fitness goals are important
to you?!
☐Get fitter !
☐Get stronger !
☐Build muscle!
☐Lose body fat!
☐Other: _______________!
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Trainer’s Notes:!
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I want to feel: !
☐More awake!
☐Healthier!
☐More relaxed !
☐More in control!
☐Other: _______________!
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I want to have:!
☐More time!
☐Less stress!
☐More energy!
☐More fun!
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Why are your goals important to you?: __________________________
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COMMITMENT!
How important is it that you achieve the above goals?
☐Not very!
☐Somewhat!
☐Very!
☐Extremely!
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What areas are you willing to work on to achieve these goals?!
☐Exercise!
☐Nutrition!
☐Stress/Mood!
☐Other: ____________________!
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MOTIVATION!
Which phrase(s) best describes your motivation levels?!
☐I am self motivated.!
☐I find exercise easier to stick to if I have a partner.!
☐I find exercise easier with regular appointments.!
☐I usually have some problems staying motivated.!
☐I need constant motivation.!
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What are you expecting from your trainer?: ______________________
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Is there anything else your trainer should be aware of?: ____________
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