Personal Health History Form

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Activity Level Information

1. My current level of activity is:   ___Sedentary    ___Mildly Active    ___Active    ___Competitive ___Elite

2. I currently work out approximately  ___0-2    ___3-4    ___5-6     ___>6 days a week.

3. Realistically, my schedule will permit me to work out   ___2-3    ___4    ___5    ___6     ___>6 days a week.

4. A typical strength workout takes me about ______ minutes  to complete, cardio takes me ______ minutes.

5. I include the following in my exercise program: (mark all that apply):  ___Flexibility    ___Strength    ___Cardiovascular training   ___Climbing Gym  ___Sport Specific Skills

6. I mainly exercise:  ___mornings  ___noon  ___afternoons   ___evenings  ___weekends  ___whenever I can

7. Have you ever met with a fitness consultant or personal trainer before? ___Yes    ___No

8. Do you train with any special gear (orthotics, belts, tape, wraps, braces, etc.) when you exercise?  ___Yes     ___No

9. What is your primary objective in seeking Web Trainer assistance?  What would you like MOST to accomplish in the next 3-6 months? The more specific you can be the more prcisely we can help you reach your goal.

10. What is absolutely necessary for you to get out of training with your Web Trainer for you to feel like the experience was worth your time, expense and effort?

11.  How did you initially hear about us?

Exercise Experience

1.  How many years of experience do you have with each of the following:

a) cardiovascular exercise? ________  b) machine weights or classes?  _________ c) free weights?   ___________

2. Please comment on your experiences with any of the following:  Body resistance strength training, exercise bands/surgical tubing, yoga/breathing techniques, medicine ball training, Stability ball/balance training, Plyometrics, interval training

3  How often do you change your workout program? What variables do you change in your workouts?

4. If you would like, please share your top 3 physical acomplishments or experiences.

5. What areas of your body are you especially interested in working on?

6. Comment on any significant team/individual sports you have been involved in since high school, including position/specialty, level attained, start date and end date:

On a separate piece of paper, share with us a typical week in your exercise routine, including number of sets and repetitions for strength training, amount of time for cardio sessions and favorite cardio activities, frequency of workouts, etc.

Health Conditions

Do you currently have any injuries that would limit your participation in an exercise program? ___Yes ___No

Do you currently suffer from any pain when you exercise? ___Yes ___No

Have you ever seen any of the following health practitioners: (check any that apply)  

___Surgeon    ___Chiropractor     ___Physical Therapist     ___Massage Therapist     ___Deep tissue or active release practitioner    ___Nutritionist or RD    ___Acupuncturist     ___Other (please list)

Do you now experience, or in the past 6 months have you suffered from, any of the following conditions?   Circle where applicable, and indicate Right (R) or Left (L) beside circles.

Comment on the duration and severity of injuries or health conditions listed above. Are they still affecting you now

Are you on any medications (besides vitamins) and if so, how long?  If you have recently (within 6 months) seen any health practitioners listed above, comment on why and what results you had.

Nutrition Issues

1. How many times do you eat a day (on average)? ___ 2 meals    ___3 meals     ___4 meals    ___5 meals    ___grazing throughout the day

2. What is a "typical breakfast?"

3. What is a "typical snack?"

4. Do you try to follow any specific "diet" plan out there?  If so, how did you choose the one you're on?

5. Have you ever used diet pills or shakes? ___Yes    ___No         Supplements?___Yes    ___No       Do you take a multi-vitamin?___Yes    ___No

6. Have you ever consulted a nutritionist or dietitian? ___Yes    ___No

7. What is your primary nutrition concern or goal?

8. What is your main source of a) iron? b) calcium? c) protein?

9. Record for 3 days (not changing anything) a)what you eat & drink b) how much c) time eaten d) on a scale of 1-10 (1= very hungry 10= very full) rate how you feel (1) 10 min. before you eat (2) 15 min. after you finish. This is to estimate a baseline "maintenance" caloric intake & identify problem nutrition areas.

Measurements

We need one last batch of information from you.  For the following, please have a friend or family member help you take and record the following measurements using a piece of string and yard (or meter) stick, or a flexible tape measure.  Remember, record AS IS!  This helps us establish a baseline and help you create a realistic, workable set of goals.  These will remain totally confidential. Please indicate what system you are using:

____English (pounds, inches, ounces)       ____Metric (kilos, cm, grams)