Client History Form

Our Promise

Our Wellness Specialists promise to provide a professional and courteous experience in order assist in meeting your health and fitness goals.

Mission Statement

Our Wellness Specialists believe your wellness is the ability to balance your life. We help you make yourself a priority.

We are dedicated to assist you in balancing your health and fitness through a focused, safe and individualized program.

Completing the Client History Form offers our Wellness Specialists the most recent information about you and your family history. The more information we have about your physical health, the better and more comprehensive your program.



Please complete all of the following fields before submitting this form.


Describe any specific changes you’d like to make through your overall fitness program? (required)

General Client Information


Name

Primary Address

Other Residence (if applicable)

Home Phone
Telephone Format Must be (###)###-####

Mobile Phone
Telephone Format Must be (###)###-####

Occupation

Work Phone Phone
Telephone Format Must be (###)###-####

Email

Website

Date of Birth

Age

Height

Weight

Pant Size

Shirt Size

Dress Size

Children
How many and names

Grandchildren
How many and names

Hobbies

Emergency Contact

Name

Phone

Date you can start training

Medical Information


Doctor's Name

Phone

Fax

Address

Street Address

City

State

Zip Code

Referral Information


Who referred you to us?

How did you find us?

Health and Wellness Questionnaire


Current Fitness Habits

Strength Training

PoorFairGoodGreatExcellent

Cardio

PoorFairGoodGreatExcellent

Flexibility

PoorFairGoodGreatExcellent

Current Nutritional Habits

Overall Daily Diet

Very UnhealthyUnhealthyAverageHealthyVery Healthy

Breakfast

Very UnhealthyUnhealthyAverageHealthyVery Unhealthy

Lunch

Very UnhealthyUnhealthyAverageHealthyVery Unhealthy

Dinner

Very UnhealthyUnhealthyAverageHealthyVery Unhealthy

Snacks

Very UnhealthyUnhealthyAverageHealthyVery Unhealthy

Barriers
Select all that apply

No TimeToo TiredUnsure where to startExercise hurts my joints/musclesI dislike exercise or find it boringToo many priorities (home, work, family, etc.)Work too much"Why bother"

I am interested in learning more about:


Strength Training Programs

Not At AllSomewhat InterestedVery InterestedExtremely Interested

Cardiovascular Programs

Not At AllSomewhat InterestedVery InterestedExtremely Interested

Flexibility Programs

Not At AllSomewhat InterestedVery InterestedExtremely Interested

Stress Management Programs

Not At AllSomewhat InterestedVery InterestedExtremely Interested

What type of weight loss have you been involved with?


Diet

Year

Weight Lost

Weight Returned

Medical History


Last Physical

Alchoholism

YesNo

Type - Date - Family Member Affected

Anemic

YesNo

Type - Date - Family Member Affected

Arthritis

YesNo

Type - Date - Family Member Affected

Back Injuries

YesNo

Type - Date - Family Member Affected

Blood Pressure

YesNo

Type - Date - Family Member Affected

Cancer

YesNo

Type - Date - Family Member Affected

Cholesterol

YesNo

Type - Date - Family Member Affected

Circulatory Disease

YesNo

Type - Date - Family Member Affected

Diabetes-A1C

YesNo

Type - Date - Family Member Affected

Drug Abuse

YesNo

Type - Date - Family Member Affected

Drug Allergies

YesNo

Type - Date - Family Member Affected

Epilepsy

YesNo

Type - Date - Family Member Affected

Eye Disease

YesNo

Type - Date - Family Member Affected

Gout

YesNo

Type - Date - Family Member Affected

Heart Attack

YesNo

Type - Date - Family Member Affected

Heart Disease

YesNo

Type - Date - Family Member Affected

Hernia

YesNo

Type - Date - Family Member Affected

Major Illness

YesNo

Type - Date - Family Member Affected

Mental Health

YesNo

Type - Date - Family Member Affected

Muscle Injuries

YesNo

Type - Date - Family Member Affected

Neck Injuries

YesNo

Type - Date - Family Member Affected

Obesity

YesNo

Type - Date - Family Member Affected

Pregnant - Postpartum

YesNo

Type - Date - Family Member Affected

Renal Disease

YesNo

Type - Date - Family Member Affected

Respiratory Disease

YesNo

Type - Date - Family Member Affected

Surgeries

YesNo

Type - Date - Family Member Affected

Thyroid

YesNo

Type - Date - Family Member Affected

Other

YesNo

Type - Date - Family Member Affected

Have you ever experienced any of the following while walking, climbing stairs, working, or exercising?


Shortness of Breath

YesNo

Lightheadedness

YesNo

Tightness in chest

YesNo

Confusion

YesNo

Pain in the shoulders

YesNo

Calf pain promptly relieved by resting

YesNo

Pain in the neck or jaw

YesNo

Dizziness

YesNo

Pain in the back

YesNo

Rapid Heart Beat

YesNo

Innapropriate Breathlessness

YesNo

Palpitations

YesNo

Faintness

YesNo

List any medications you currently use?

What are your goals?

What do you want to change about yourself through a fitness program?

What are your priorities in improving your fitness?
Check all that apply

Improve cardiovascularBuild muscle strengthIncrease physical flexibilityIncrease overall muscle toneQuit smokingDevelop new recreational interestsLearn to cope better with responsibilitiesLose weightGain weightImprove postureImprove nutritional habitsFind healthy ways to relax

What are the four most important body parts you want/need to change?


1

2

3

4

How often would you like to exercise per week?

What is your blood pressure?

What does the Systolic number mean? Systolic or the top number, shows the pressure in your arterieswhen your heart is forcing blood through them.

What does the Diastolic number mean? Diastolic or the bottom number, shows the pressure in yourarteries when your heart relaxes.

The top number can be anywhere from 90 to 240 and the bottom number can be anywhere from 60 to140. Blood pressure is measured in millimeters of mercury, which is written down as: mmHg


Systolic

Diastolic

What is your Heart Rate?

How many beats per minute does your heart push blood throughout your body is measured in:

Beats per minute

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