Health & Medical Questionnaire

Name *
Name
Phone *
Phone
Date of Birth *
Date of Birth
Address *
Address
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
Name of your Physician *
Name of your Physician
Phone Number of your Physician *
Phone Number of your Physician
Present/Past History *
Have you had OR do you presently have any of the following conditions? (Check if yes.)
Family History *
Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)
3. Are you presently employed? *
6. Have you ever worked with a personal trainer before? *
7. Date of your last physical examination performed by a physician: *
7. Date of your last physical examination performed by a physician:
Make an approximation if you don't recall the exact date.
8. Do you participate in a regular exercise program at this time? *
9. Can you currently walk 4 miles briskly without fatigue?
10. Have you ever performed resistance training exercises in the past? *
11. Do you have injuries (bone or muscle disabilities) that may interfere with exercising? *
Do you smoke? *