Health History Form "*" indicates required fields Step 1 of 6 16% First Name* Last Name* Address* Street Address Address Line 2 City State *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Emergency ContactEmergency Contact First Name* Emergency Contact Last Name* Emergency Contact Phone*How did you find us?* Health HistoryThis form is used to assess your present health and fitness status and it is not used to diagnose any medical condition/s. Please answer all the questions completely and to the best of your ability. If you do not know the answer to a question leave it blank and we will go over it again in person. The more accurate your answers the more we can help!Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?* Yes No Heart Condition CommentsDo you feel pain in your chest when you perform physical activity?* Yes No Chest Pain CommentsIn the past month, have you had chest pain when you were not performing any physical activity?* Yes No Chest Pain During Physical Activity CommentsDo you lose your balance because of dizziness or do you ever lose consciousness?* Yes No Dizziness CommentsDo you have a bone or joint problem that could be made worse by a change in your physical activity?* Yes No Bone or Joint Problem CommentsDo you have high blood pressure?* Yes No High Blood Pressure CommentsDo you have high blood sugar?* Yes No High Blood Sugar CommentsDo you have high cholesterol?* Yes No High Cholesterol CommentsHave you had a surgical procedure within the last 5 years?* Yes No Please List & Describe SurgeriesProblems with hearing?* Yes No Hearing CommentsProblems with vision?* Yes No Vision CommentsDate of last physical?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Physician's Name* Injuries*Check box associated with any injury, basic details and year. Broken bones Muscle strain/joint sprain Ligament, tendon or cartilage injury Joint injury or chronic pain None Broken Bones: Give year and basic detailsMuscle strain/joint sprain: Give year and basic detailsLigament, tendon or cartilage injury: Give year and basic detailsJoint injury or chronic pain: Give year and basic detailsAre you currently being treated for any injuries?* Yes No Basic description of injury treatment: Do you have any chronic or serious illnesses?* Yes No Basic description of chronic or serious illnesses:Are you presently taking any medications?* Yes No Basic description of medications:Do you have any allergies? (Include all medications)* Yes No Basic description of allergies:Are you currently pregnant, or have you been in the past year?* Yes No Pregnancy CommentsHave any of your parents of siblings had heart disease before age 55?* Yes No Heart Disease CommentsDo you currently smoke cigarettes?* Yes No How many cigarettes a day?Have you ever been a smoker?* Yes No When did you quit?*Please enter a number greater than or equal to 1990.Smoking CommentsDo you have regular and healthy bowel movements?* Yes No Bowel Movement CommentsWhat is your present weight? (lbs)*What is your height?*What is your height?5' 0" and under5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"5' 12"6' 0"6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"6' 7"6' 8"6' 9"6' 10"6' 11"7' 0"7' 1"7' 2"7' 3" and tallerHave you ever seen a nutritionist or dietician?* Yes No Nutritionist/Dietician CommentsDoes your job require you to travel?* Yes No How often?*How often? *Every day5 days per weekOnce a week2 to 3 times a weekOnce a month2 to 3 times a monthLess than once a monthDo you commute to work?* Yes No How many miles each way?Do you have children?* Yes No What is/are their age(s)? What are your expectations of either personal training, physical therapy and/or muscle activation techniques?*What outcomes are you expecting from either personal training, physical therapy and/or muscle activation techniques?*What is the most important goal for you to achieve with your program?*What is the most important goal for you to achieve with your program?*What is the most important goal for you to achieve with your program?Weight LossWellnessLean Body MassSport ConditioningWhy is the above goal/s important to you?*In what time frame do you expect to achieve your goal/s?*How much time per day are you willing to engage in activity that reinforce your training goals?* 10 Minutes 15 Minutes 20 Minutes 30 Minutes 45 Minutes 60 Minutes Are all the aspects of your workout completely up to you or is someone or something else a consideration when designing your program variables?*If you don’t make these changes and stay the way you are or regress in your health and fitness how would that affect your life? What consequences could occur?*When you do reach your goal/s in what way/s will life be different?*Is it more important for you to continually feel challenged or to feel structured during your workouts?* Challenged Comfortable When you need to reduce stress do you ideally enjoy activities that are exciting, adventurous and give you a chance to blow off steam or activities that are relaxing?* Exciting Relaxed Do you enjoy exercise more when it involves a routine that you can adhere to or one that offers variety?* Variety Routine Do you enjoy exercise more when it involves a routine that you can adhere to or one that offers variety?* Yes No Occupation / LIfestyleDoes your occupation require repetitive movements?* Yes No Repetitive Movements CommentsDoes occupation cause you anxiety or mental stress?* Yes No Occupation Stress CommentsWould you say that your work is sedentary, active or physically strenuous?* Sedentary Active Strenuous What style of hobby do you enjoy?* Active Inactive Do you regularly participate in recreational activities?* Yes No What types of exercise or recreational activities are you currently participating in?Recreational activities frequency:* Daily Weekly Monthly Do you have an exercise space and/or exercise equipment at home? ** Yes No Please describe your exercise space and/or exercise equipment at home:* Consent and Release FormI hereby expressly consent to my participation in personal and/or small group training at Regular Exercise LLC. I acknowledge that such participation will necessarily involve participation in exercises that may be physically demanding and will subject the participant to stress, anxiety and possible hazards. I understand that the activity involves inherent other risks of INJURY. I voluntarily agree to expressly assume all such risks that may result from the activity or in any way related to my participation in the activity. In consideration of the right to participate in the activity, I hereby release from any legal liability Regular Exercise LLC, and its instructors and all individuals assisting with the activity for injury or death caused by or resulting from my participation in the activity or in any way connected with my participation in the activity, whether such injury or death was caused by the alleged negligence of Regular Exercise LLC, another participant, or any other person or cause. This agreement will apply for each and every day I engage in the activity without requiring me to sign an additional form for each. I further agree to defend and indemnify Regular Exercise LLC for loss or damage, including any that result from claims or lawsuits for personal injury, death, or personal property damage, relating to the activity of the Regular Exercise LLC facilities or equipment. I represent that I am in satisfactory physical condition to participate in the activity and I authorize any person connected with the activity at Regular Exercise LLC to administer first aid to me, as they deem necessary. I authorize medical and surgical care and transportation to a medical facility or hospital for treatment necessary for my well being, at my expense. The undersigned, (individual, parent or guardian) acknowledges that she/he is signing this agreement on behalf of (themselves, or a minor) and that the individual or minor shall be bound by the terms of the agreement.Agreement and Consent* I Agree Signature*Type your full name as agreement and consent. Parent/Legal Guardian Agreement and Consent for age under 18Parent/Legal Guardian Agreement and Consent for age under 18* I Agree Parent/Legal Guardian Signature*Type your full name as agreement and consent. Δ
