Client Medical History Form
General Patient Information
Client Name
*
First Name
Last Name
Phone Number
Client E-Mail
*
example@example.com
Client Gender
*
Please Select
Male
Female
Client Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Client Height (inches)
*
Client Weight (lb's)
*
Body fat %
Client Medical History
Have you ever had (Please check all that apply)
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Emotional Disorder
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
Any family history of the above, If yes, please explain:
Any other medical problems/concerns not already identified?
Please list any injuries and Dates of Each
Please list your Current Medications/supplements
Healthy & Unhealthy Habits
Occupational activity level:
Please Select
sedentary
Light
moderate
heavy
Exercise
Never
1-2 days
3-4 days
5+ days
Are you currently following a structured exercise plan? If yes, please explain.
How many days do you strength train?
1
2
3
4
5
6
7
Do you train at home or in a gym?
home
gym
What is your typical strength training routine?
What strength equipment do you have available to you?
Do you do cardiovascular exercise?
Yes
No
How many days do you do cardio AND How many minutes each day?
If yes, What is your typical weekly cardiovascular routine?
What exercises interest you?
walking
swimming
stationary bike
stairclimber
rowing
jogging
eliptical
yoga
pilates
strength training
Other
What are your eating habits?
I have a loose diet
I have a strict diet
I don't have a diet plan
Have you ever followed a specific nutritional plan?
Yes
No
If yes, Who created it for you and what did it consist of?
What were your results?
What is a typical weekday and weekend of nutrition for you?
What foods do you like?
What foods do you dislike?
Alcohol Consumption
I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Caffeine Consumption
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Include other comments regarding your Medical History
Submit
Should be Empty: