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Elite Personal Training and Fitness Solutions Health History Questionnaire

Name

Home Address

Email Address

Date of Birth

Age

Phone Number

Height

Weight

Sex

Male

Female

Marital Status

Single

Married

Other

Fitness/Goals

Present Medical History (please check off if you have had any of the prolems listed below)

High Blood Pressure

Cancer

Diabetes

Kidney Disease/Stones

Stroke

Emphysema

Bronchitis

Pneumonia

Heart/Attack Disease

Gall Bladder Disease

Thyroid Disease

Prostate Problems

Asthma

Chest Pain/Tightness

Hepatitis

Depression

Arthritis

Mental Illness

Operations (specify)

Hospitalized (specify)

Other (specify)

Review of Systems

Joint Swelling

Muscle Ache

Skin Rashes

Daytime/Sleepiness

Dizziness

Joint Pain (at rest or after activity)

Fatigue

Insomnia

Chest Pain

Numbness - Tingling

Frequent Urination

Shortness of Breath (at rest or after activity)

Swollen Ankles

Palpitations

Night Sweats

Sudden Weight Loss

Frequent Headaches

Other (specify)

Family History - Has any of your family (includes parents, grandparents and siblings) ever had any of the following?

Cancer

High Blood Pressure

Heart Disease

Stroke

Arthritis

Mental Illness

Emphysema

Which Family Member?

Please list current medications and any allergies to medications.

Dosage

Do you smoke?

No

Yes

If yes, how many packs per day?

How many years?

Do you drink alcoholic beverages?

No

Yes

If yes, how much per day?

Do you use drugs?

Please provide best and worst days/times of the week for training:

BEST DAYS:

Monday

Tuesday

Wednesday

Thursday

Friday

Flexible

BEST TIMES:

Early AM

AM

Late AM

Mid Day

Early PM

PM

Flexible

WORST DAYS:

Monday

Tuesday

Wednesday

Thursday

Friday

WORST TIMES:

Early AM

AM

Late AM

Mid Day

Early PM

PM

Other (specify)

Is there anything else you would like us to know about you?

Your Signature

Thanks for submitting!

Elite Personal Training and Fitness Solutions | 215-947-2099 |1800 Byberry Rd # 703 Huntingdon Valley, PA 19006 |

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