Your Health History Form
Please print this page, fill it out and mail to:
562 West 261st Street
Riverdale, NY 10471
Zip______________Employer_______________________Type of Work_____________
In Case of Emergency Contact___________________Phone_______________________
Date of last physical Exam_________Blood Pressure________Resting HR___________
Training HR__________ E-mail ____________________________________________
Please check the following items as each is applicable to your health. This information will help to design your fitness program. Be sure to circle yes or no.
!. Medical Background
Please circle yes or no.
Yes No High blood pressure? If yes, describe__________________________________
Yes No Heart problem? If yes, describe______________________________________
Yes No Is there a history of heart disease in the family? (i.e. heart attacks, stroke, etc.)
Yes No Have you ever experienced a heart palpitation/irregular heart beat?
Yes No Have you ever had chest pains?
Yes No Have you ever experienced dizziness or fainting spells?
Yes No Have you ever had problems with breathing or been diagnosed as asthmatic?
Yes No Do you have allergies or hay fever? If yes, describe_____________________
Yes No Do you get short of breath from mild exertion?
Yes No Do you have epilepsy?
Yes No Are you diabetic or have a family history or diabetes? If yes, describe ________________________________________________________________________
Yes No Have you ever been diagnosed as being hypoglycemic?
Yes No Do you experience any neck pain? If yes, describe______________________
Yes No Do you suffer from any back pain? If yes,
Yes No Have you ever had a hernia? If yes, describe___________________________
Yes No Have you ever suffered a joint injury? If yes, describe___________________
Yes No Do you have high cholesterol? If yes, describe_________________________
Yes No Do you smoke? If yes, how many packs or cigarettes per day? ____________
Yes No Are you an ex-smoker? If yes describe________________________________
Yes No Do you fast? If yes, describe________________________________________
Yes No Are you under a doctorís care for a current illness? If yes, describe_________________________________________________________________
Yes No Have you been recently hospitalized? If yes, describe_________________________________________________________________
Yes No Are you currently using medication that may affect your physical performance? If yes, describe_______________________________________________
Yes No Do you take allergy medication? If yes, describe________________________
Yes No If applicable, are you currently, or were you recently pregnant? If yes, describe_________________________________________________________________
NOTE: If you answered yes to any of the questions above, please see your physician prior to beginning your training program.
Please check the following items that best describes your current daily activity level. This information will help me to understand your current ability to exercise. Be sure to circle yes or no.
Yes No Are you active or inactive on your work? Please describe ________________________________________________________________________
Yes No Are you exercising regularly now? If yes, describe_________________________________________________________________
Yes No Are you overweight? If yes, how much weight would you like to lose? ___________________________________________________________________
LEAVE FOR ME
PERSONAL TRAINING AGREEMENT
It is strongly recommended that you get a physical examination by your physician every year
Overview of Current Condition
After reviewing your health history and analyzing your current level of physical activity, we will explain the results and provide you with an exercise program. Therefore, it is strongly recommended that you ask questions about your program.
As a participant of the Personal Training Program, you will be provided with ongoing evaluations to determine your progress and to adjust you program accordingly.
Before we start your training program, we would like to point out a few important details.
I am voluntarily participating in the Personal Training Program which has been explained to me verbally and in writing. I am aware of my own current level of health and physical condition. I am also aware that participating in any exercise training program has inherent risks of injury. I agree that I will contact my physician. If I need any medical attention.
Personal Trainerís Signature Date