Medical History, Activity History, Baseline health status
Detailed medical history and health status are needed prior to starting an exercise training program for client safety. Clients are responsible for reporting any relevant ​changes to their health status. ​
Demographics
Name *
Your answer
DOB *
MM
/
DD
/
YYYY
Today's date *
MM
/
DD
/
YYYY
Street address *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Email *
Your answer
Cell phone *
Your answer
Phone/other
Your answer
Emergency Contact - Name and relationship *
Your answer
Emergency Contact - Phone *
Your answer
Primary care physician
Your answer
Phone
Your answer
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