Health History Form

First name

Last name

Email

Address

Date of birth

Month

Day

Year

Current Physician

Phone Number of Physician

Email of Physician

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

Are you under the care of a physician, chiropractor, or other health care professional for any reason (circle)? If yes, list reason:

No

Yes

What is the reason you are under the care of a medical professional? (write NA if not applicable)

Are you taking any medications?

No

Yes

If yes (to taking medications), please list the following: Medications, Dosage/Frequency, Condition

List any and all allergies

Has your doctor ever diagnosed you with high blood pressure?

No

Yes

Has your doctor ever diagnosed you with a bone or joint problem that has been or could be made worse by exercise?

No

Yes

Are you over 65 years of age?

No

Yes

Are you used to vigorous exercise?

No

Yes

Is there any reason not mentioned why you should not follow a regular exercise program? If yes, please explain:

No

Yes

If yes, please explain why you should not follow a regular exercise program (write NA if not applicable).

Have you recently experienced any chest pain associated with either exercise or stress? If yes, please explain:

No

Yes

If yes, please explain why you have experienced chest pain (write NA if not applicable).

Do you consume Caffeine?

No

Yes

Do you consume Alcohol?

No

Yes

Do you experience Anemia?

No

Yes

Do you have a Gastrointestinal Disorder?

No

Yes

Do you have Hypoglycemia?

No

Yes

Do you have a Thyroid Disorder?

No

Yes

Are you Pre/Postnatal?

No

Yes

If you have any other health disorders that you feel are relevant to disclose, please list them here (write NA if not applicable):

Do you have high blood pressure?

No

Yes

Do you have hypertension?

No

Yes

Do you have high cholesterol?

No

Yes

Do you have hyperlipidemia?

No

Yes

Do you have heart disease?

No

Yes

Have you had a heart attack?

No

Yes

Have you had a stroke?

No

Yes

Do you have angina?

No

Yes

Do you have gout?

No

Yes

If you have any other health conditions that you feel are necessary to disclose, please list them here (write NA if not applicable):

Smoking: Please check the box that describes your current habits.

Please list any physical pain you have been experiencing as well as surgeries that you have undergone (write NA if not applicable).

Write or mention any pain you have experienced in your body (eg. head and neck, upper back, lower back, shoulder, arm or elbow, wrist or hand, hip or pelvis, knee or thigh, arthritis, hernia, surgeries, other)

Are you on a specific nutrition plan (food or diet plan)?

No

Yes

What nutrition (food or diet) plan are you on and who prescribed it?

What dietary supplements do you take?

Do you notice your weight fluctuating?

No

Yes

Have you experienced a recent weight gain or loss?

No

Yes

Over what amount of time have you experienced weight gain or loss?

How many beverages do you consume per day that contain caffeine? What are they?

How would you describe your current nutritional behaviors?

Other food/nutritional issues you want to include (food allergies, mealtimes, etc.)

Anything else you would like your coach to know when it comes to your nutrition?

Statement of Acknowledgement

Agree

"I certify that the information I have provided in my health history is true and complete to the best of my knowledge. I understand that any omission or misstatement of material facts may invalidate my this document. I authorize the release of this medical form to necessary health care professionals."

Name

Signature

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I declare that the info I’ve provided is accurate and complete.