Health History Form 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: Δ
