Health History Form

CLIENT HEALTH HISTORY & INFORMATION QUESTIONNAIRE

Please fill out the following form completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals, interests and that is safe and effective. All information received on this form will be treated as strictly confidential.

Date of Birth:








 

Emergency Contact Information:




 

Physician's Information:





Muscles in Motion, Inc. Personal Training may send information regarding your physical exercise program to your physician unless you request otherwise.

 

Training Related Questions

How far do you live from our training studio? miles

Did you know that Muscles in Motion offers Golf Fitness as well as Personal Training? YESNO

Would you like to know more about our TPI Certified Golf Fitness trainers and program? YESNO

 

Fitness History

When were you in the best shape of your life?

Have you been exercising consistently for the past 3 months? YESNO

When did you first start thinking about getting in shape?

What, if anything, stopped you in the past?

On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?

 

Lifestyle Related Questions

Do you smoke? YESNO If yes, how many?

Do you drink alcohol? YESNO If yes, how many glasses per week?

Describe your job: SedentaryActivePhysically Demanding

Does your job require travel? YESNO

On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?

List your 3 biggest sources of stress:

Is anyone in your family overweight? MotherFatherSiblingGrandparent

Were you overweight as a child? YESNO If yes, at what age(s)

 

Nutrition Related Questions

On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?

How many times a day do you usually eat (including snacks)?

Do you skip meals? YESNO

Do you eat breakfast? YESNO

Do you eat late at night? SometimesOftenNever

What activities do you engage in while eating?

How many glasses of water do you consume daily?

Do you feel drops in your energy levels throughout the day? YESNO If yes, when?

Do you know how many calories you eat per day? YESNO If yes, how many?

Are you currently or have you ever taken a multivitamin or any other food supplements? YESNO

If yes, please list the supplements:

At work or school, do you usually: Eat outBring food

How many times per week do you eat out?

Do you do your own grocery shopping? YESNO

Do you do your own cooking? YESNO

Besides hunger, what other reason(s) do you eat? BoredomSocialStressTireDepressedHappyNervous

Do you eat past the point of fullness? SometimesOftenNever

Do you eat foods high in fat and sugar? SometimesOftenNever

List 3 areas of your Nutrition you would like to improve:

PLEASE PROVIDE 24 HOUR NOTICE IF YOU NEED TO CANCEL OR RESCHEDULE YOUR TRAINING APPOINTMENT AT MUSCLES IN MOTION.  THANK YOU!