Health History Questionnaire and Goals Worksheet

This Form and Your Confidentiality

This health history form is your opportunity to provide information that will assist our fitness coaches in evaluating your current level of health and fitness. Fitness Excellence®, LLC will maintain this form and the information you provide in a manner that assures your confidentiality. Any information you provide will be available only to the fitness coaches of Fitness Excellence®, LLC and will be used solely in conjunction with planning and developing health and
fitness programs.

Name First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Today's Date * / MM / DD YYYY
Mobile Phone - ### - ### ####
Home Phone - ### - ### ####
Email
Primary Physician's Name First Last
Primary Physician's Phone # - ### - ### ####
Emergency Contact Name First Last
Emergency Contact Phone # - ### - ### ####
Date of Birth * / MM / DD YYYY
Height (feet)
Height (inches)
Weight (lbs)
Health History
Please indicate your history related to each of the following conditions by checking the appropriate box. If you have
had any condition(s) in the past, please indicate the date in the appropriate space.

Heart murmur, clicks, or other cardiac findings
Never Now Have Had
If you have had heart murmer, clicks or other cardiac findings,
please enter in the date / MM / DD YYYY
Frequent extra, skipped, or rapid heart
beats/palpitations
Never Now Have Had
If you have had Frequent extra, skipped, or rapid heart
beats/palpitations,
please enter in the date / MM / DD YYYY
Heart attack, coronary bypass, or other cardiac
surgery
Never Now Have Had
If you have had Heart attack, coronary bypass, or other cardiac
surgery,
please enter in the date / MM / DD YYYY
Chest pain/angina (especially upon exertion)
Never Now Have Had
If you have had, Chest pain/angina (especially upon exertion)
please enter in the date / MM / DD YYYY
Currently pregnant
Never Now Have Had
If you have been pregnant,
please enter in the date / MM / DD YYYY
Diagnosed with high blood pressure
Never Now Have Had
If you have been diagnosed with high blood pressure,
please enter in the date / MM / DD YYYY
Leg cramps during exercise
Never Now Have Had
If you have had leg cramps during exercise,
please enter in the date / MM / DD YYYY
Chronic swollen ankles
Never Now Have Had
If you have had chronic swollen ankles,
please enter in the date / MM / DD YYYY
Varicose veins
Never Now Have Had
If you have had varicose veins,
please enter in the date / MM / DD YYYY
Frequent dizziness/fainting
Never Now Have Had
If you have had frequent dizziness/fainting,
please enter in the date / MM / DD YYYY
Blood clot
Never Now Have Had
If you have had Blot clot,
please enter in the date / MM / DD YYYY
Severe arthritis
Never Now Have Had
If you have had severe arthritis,
please enter in the date / MM / DD YYYY
Orthopedic problem(s) or complaint(s)

Never Now Have Had
If you have had orthopedic problem(s) or complaint(s),
please enter in the date
/ MM / DD YYYY
Chronic back pain
Never Now Have Had
If you have ever had chronic back pain,
please enter in the date / MM / DD YYYY
Musculoskeletal problems(s) or complaint(s)
Never now Have Had
If you ever had musculoskeletal problems(s) or complaint(s),
please enter in the date / MM / DD YYYY
Asthma
Never Now Have Had
If you ever had Asthma,
please enter in the date / MM / DD YYYY
Cancer
Never Now Have Had
If you have had cancer,
please enter in the date / MM / DD YYYY
Diabetes
Never Now Have Had
If you have had diabetes,
please enter in the date / MM / DD YYYY
Epilepsy
Never Now Have Had
If you have had Epilepsy,
please enter in the date / MM / DD YYYY
Rheumatic Fever
Never Now Have Had
If you have had rheumatic fever,
please enter in the date / MM / DD YYYY
If you have had scarlet fever
Never Now Have Had
Scarlet Fever / MM / DD YYYY
Bronchitis
Never Now Have Had
If you have had bronchitis,
please enter in the date / MM / DD YYYY
Stroke
Never Now Have Had
If you have had a stroke,
please enter in the date / MM / DD YYYY
Pneumonia
Never Now Have Had
If you ever had Pneumonia,
please enter in the date / MM / DD YYYY
Recent Surgery (Please describe and give dates.)
Other medical problems/considerations, recent illness(es), hospitalizations(s), or injury
Current medications/prescriptions
Do you smoke?
Date of last complete medical or physical exam: * / MM / DD YYYY
Do you know of any medical or health conditions, considerations, or circumstances that might make it dangerous or unwise for you to participate in an exercise program?
Family Health History

Please indicate the number of blood relatives (mother, father, grandparents, brothers, sisters, children) who have had a heart attack prior to age 65
Have had a stroke
Have had or now have diabetes
Have been or are substantially overweight
Please answer the following questions as completely and honestly as possible.

GOAL #1:
GOAL #2
GOAL #3
Please describe your typical exercise routine. If you don’t currently exercise or haven’t exercised in the past skip this section.

How many times per week?
How long per session? (in minutes)
What are your favorite types of exercise methods? (Ex: treadmill, bike, running, swimming, weights, types of machines)
Nutritional Habits: (Please describe what you typically eat and drink for meals and snacks throughout your day.)

Breakfast:
Snack:
Lunch:
Snack:
Dinner:
Please tell us what you are looking for in a Fitness Coach. Do you prefer male or female? Drill Sergeant or Subtle Supporter? In home, in a gym, outside, in person, on–line, etc.
If you are not sure what you are looking for in a Fitness Coach, but know you want someone to motivate you, educate you and tell you what you need to do to achieve your level of Fitness Excellence®, leave this section blank.
The information submitted on this Health History and Goals Form is true and complete to the best of my knowledge, and I understand that any wrong or incomplete information could result in a less effective fitness program, injury, or illness.

Signature (entering your name here is an electronic signature) *
Signature of Parent or GUARDIAN
(for participants under the age of 18)

Entering your name here is an electronic signature
Date * / MM / DD YYYY