PERSONAL HEALTH HISTORY
Name _____________________________________________
Date ______________________________________
Address _________________________________________________________________________________________
Home phone _______________________________
Work phone ________________________________________
Emergency contact __________________________
E-mail address ______________________________________
Gender male _____
Age ____________
female _____
Birthdate __________________
Weight ____________
Height _____________
Physicians name ______________________________ Physicians phone __________________________
Does your physician know that you are participating in an exercise/fitness program? yes ____ no ____
Date of last physical examination ___________________________________________________________________
Are you taking any medications?
no ____ yes ____ (Please list medications and reasons for usage below)
Medication
Reason for usage
Are you taking any vitamins or dietary supplements?
no ____ yes ____ (Please list supplements and reasons for usage below)
Supplement
Reason for usage
Do you now, or have you had in the past:
yes
no
1. History of heart problems, chest pain or stroke?
2. Increased blood pressure?
3. Any chronic illness or condition?
4. Do you ever get dizzy, lose your balance or lose consciousness?
5. Difficulty with physical exercise?
6. Advice from physician not to exercise?
7. Recent surgery (last 12 months)?
8. Pregnancy (now or within last 3 months)?
9. History of breathing or lung problems?
10. Swollen, stiff, or painful joints?
11. Foot problems?
12. Back problems?
13. Any significant vision or hearing problems?
14. Diabetes or thyroid condition?
15. Cigarette smoking habit?
16. Do you ever drink alcoholic beverages?
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17. Increased blood cholesterol?
18. History of heart problems in immediate family?
19. Hernia, or a condition that may be aggravated by lifting weights?
20. Do you have asthma?
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Please explain any yes answers below. (If necessary use the back of this page)
Do you have any other medical conditions or problems not previously mentioned?
If so, please explain.
FAMILY HISTORY
Father
Current age ___________
Fathers general health is:
excellent ___
good ___
fair ___
poor ___
Reason for fair/poor health is? __________________________________________________
Mother
Current age ___________
Mothers general health is:
excellent ___
good ___
fair ___
poor ___
Reason for fair/poor health is? __________________________________________________
Siblings
Number of brothers __________
Number of sisters __________
Age range ____________
Any health problems? Please explain. __________________________________________________
_____________________________________________________________________________________
Have any of your BLOOD relatives had:
yes
no
1.
2.
3.
4.
5.
6.
7.
8.
9.
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Heart attack under age 50?
Stroke under age 50?
High blood pressure?
Elevated cholesterol?
Diabetes?
Asthma or hay fever?
Heart operations?
Obesity?
Leukemia or cancer under age 60?
EXERCISE AND PHYSICAL ACTIVITY
For the following questions, please mark which best applies to you.
Are you currently involved in a regular fitness program?
Are you involved in physical activities of daily living?
(walking, gardening, etc.)
If yes, what type and how often?
yes ___
yes ___
no ___
no ___
Are you involved in cardiovascular exercise or a group fitness program?
If yes, what type and how often?
Are you involved in a strength training/weight lifting program? yes ___
If yes, what type and how often? 2
Are you involved in any sports? yes ___
If so, what sports and how often?
yes ___
no ___
no ___
no ___
For the following questions, mark which best applies to you.
Do you consider yourself:
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sedentary
lightly active (sporadic workouts, lawn work, little aerobic work)
moderately active (work out 1-2 days/week for at least 15-30 minutes)
highly active (work out three or more days/week at least 30-45 minutes)
Do you believe that you are physically fit?
___ no
___ average
___ less than average
___ above average
___ outstanding
___ dont know
Indicate the main reason you exercise or why you want to begin an exercise program.
___ it is good for my health
___ helps to relieve stress
___ my doctor told me to
___ I am trying to lose weight
___ it makes me feel good
___ other _________________
What activities would/do you prefer in a regular exercise program?
___ walking and/or running
___ racquetball or squash
___ swimming
___ tennis
___ stationary cycling
___ basketball
___ stretching
___ rowing
___ strength/resistance training
___ group fitness classes
___ not sure
___ other ____________________
GOAL ASSESSMENT FORM
Name ________________________________________
Goals should be: SMART
Date __________________________
(example goal: I want to lose 2 percent body fat within 6 months.)
S ~ Specific: What will you do? (i.e. lose weight)
M ~ Measurable: How will you measure it? (i.e. percent body fat, BMI)
A ~ Attainable: Is this something you can attain?
R ~ Realistic: Can you realistically reach this goal?
T ~ Set on a time line: When do you want to reach this goal?
Please fill out the goals and objectives below. You may want to wait and set these goals with the guidance of your
personal trainer.
Long term goals (Where do you want to be in 6 months to a year?)
1.
2.
3.
Short term objectives (What small things will you do to accomplish your long term goals?)
1.
2.
3.
4.
Fitness goals (may be similar to goals and objectives above)
1. Cardiorespiratory endurance
___________________________________________________________________________________
___________________________________________________________________________________
2. Muscular strength and endurance
___________________________________________________________________________________
___________________________________________________________________________________
3. Flexibility
___________________________________________________________________________________
___________________________________________________________________________________
4. Body composition/nutrition
___________________________________________________________________________________
___________________________________________________________________________________
For use of NU Fitness Staff
Notes:
