Full Name:
 Date you want to start your
personal training
 
Address:
City, State, Zip:
Date of Birth:
Phone Number:
Email Address:
Phone Number
Emergency Contact
Fitness level (1-10, 10
being the best)
Internet
 Flyer
 or
How did you find us?
Referred By
My Main Goal is to:
Comments:
MEDICAL HISTORY

If you are returning and have no medical changes, the medical section below does not need to be
completed. All agreements remain the same.

NOTICE: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition program!
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
2. Do you take any prescribed medication on a permanent or semi-permanent basis?
3. Do you have a seizure disorder (epilepsy)?
Yes
No
4. Do you have diabetes adult or juvenile?
Yes
No
Medications
5. Have you ever been found to be anemic (low
blood count)?
Yes
No
6. Do you have high blood pressure
(hypertension)?
Yes
No
Medications
7. Do you have or have you ever had the following
diseases?
Heart Disease

Lung Disease

Kidney Disease

Liver Disease
 Yes
No
Yes
No
Yes
No
Yes
No
8. Do you have athsma?
Yes
No
Medications
9. Have you ever had a severe neck injury? If yes, Describe:
Yes
No
10. Have you ever been knocked out? If yes, Describe:
Yes
No
11. Do you wear glasses or contact lenses?
 Yes
No
Yes
12. Have you had a broken bone or fracture in the past 2 years?
If yes,  Describe:
 No
Yes
13. Have you ever injured your back? If yes, Describe:
 No
Never
 Seldom
14. Do you have back pain?
 Occaisionally
Frequently, with vigorous exercise or
heavy lifting
Yes
15. Have you had knee pain in the past 2 years that has disabled
you for longer than a week? If yes, Describe:
 No
Yes
16. Do you have other physical conditions which cause pain?
If yes, Describe:
 No
17. Detail any surgical procedures:
18. If you have had your body fat tested, what is you percent body fat?
 %
Please Fill Out Completely, Print, and Bring with you to your First Class