Health History Form Muscles in Motion, Inc. Personal Training may send information regarding your physical exercise program to your physician unless you request otherwise.Name(Required) First Last Email(Required) Training Related QuestionsHow far do you live from our training studio?(Required)Did you know that Muscles in Motion offers Golf Fitness as well as Personal Training?(Required) Yes No Would you like to know more about our TPI Certified Golf Fitness trainers and program?(Required) Yes No Fitness HistoryWhen were you in the best shape of your life?(Required)Have you been exercising consistently for the past 3 months?(Required) Yes No When did you first start thinking about getting in shape?(Required)What, if anything, stopped you in the past?(Required)On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?Please enter a number from 1 to 10.Lifestyle Related QuestionsDo you smoke?(Required) Yes No How many?(Required)Do you drink alcohol?(Required) Yes No How many glasses per week?(Required)Describe your job:(Required) Sedentary Active Physically Demanding Does your job require travel?(Required) Yes No On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?Please enter a number from 1 to 10.List your 3 biggest sources of stress:(Required)Is anyone in your family overweight?(Required) Mother Father Sibling Grandparent Were you overweight as a child?(Required) Yes No If yes, at what age(s)(Required)Nutrition Related QuestionsOn a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?(Required)Please enter a number from 1 to 10.How many times a day do you usually eat (including snacks)?(Required)Do you skip meals?(Required) Yes No Do you eat breakfast?(Required) Yes No Do you eat late at night?(Required) Sometimes Often Never What activities do you engage in while eating?(Required)How many glasses of water do you consume daily?(Required)Do you feel drops in your energy levels throughout the day?(Required) Yes No When do you feel your energy drop?(Required)Do you know how many calories you eat per day?(Required) Yes No How many calories do you eat in a day?(Required)Are you currently or have you ever taken a multivitamin or any other food supplements?(Required) Yes No What supplements?(Required)At work or school, do you usually:(Required) Eat out Bring food How many times per week do you eat out?(Required)Do you do your own grocery shopping?(Required) Yes No Do you do your own cooking?(Required) Yes No Besides hunger, what other reason(s) do you eat?(Required) Boredom Social Stress Tired Depressed Happy Nervous Do you eat past the point of fullness?(Required) Sometimes Often Never Do you eat foods high in fat and sugar?(Required) Sometimes Often Never List 3 areas of your Nutrition you would like to improve:(Required) Δ
