Health History
Email address *
Date of Birth *
MM
/
DD
/
YYYY
Full Name *
Your answer
Age *
Your answer
Address *
Your answer
Phone *
Your answer
Family Doctor's Name *
Your answer
Doctor's Phone Number *
Your answer
Do you currently exercise 2 or more times per week? *
If yes, please describe your workout *
Your answer
What 3 goals would you like to work toward over the next few weeks/months? *
Your answer
Why are these goals important to you now? *
Your answer
How long have you been thinking about taking action towards these goals, and what has prevented you from taking action sooner? *
Your answer
What kind of activities do you like, or would like to take part in? *
Required
How many days per week are you able to participate in physical activity for exercise? *
Length *
Do you have pain or have you injured any of the following areas?
Your answer
Upper Back
Lower Back
Shoulder
Elbow
Wrist
Hip
Knee
Ankle
Other
Your answer
Do you have any medical conditions?
Have you had any surgeries? If yes, please explain in detail.
Your answer
Are you taking any medication? if yes, what kind and for what condition?
Your answer
Are you pregnant? If yes, how far along are you?
Your answer
Do you smoke? *
If yes, how many per day?
Your answer
What have you had to eat or drink in the last 24 hours? Please list times as well. *
Your answer
Do you take any supplements? (i.e. Vitamins, minerals, protein, ergogenic aids)
Your answer
Do you have any allergies? If yes, please explain
Your answer
How would you rate your daily stress level? *
What time do you go to bed, and what time do you wake up in the morning? *
Your answer
What is your occupation and working hours? *
Your answer
What other health care professionals do you see or have you seen?
What role would you like your personal trainer to play in your fitness and lifestyle? *
Required
Would you workout at *
If you workout at home what equipment do you have?
(In-Person Program) On what days and what times would you commit in meeting with Dee?
Your answer
Signature and Date *
Your answer
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