Client Medical History Form

Client Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Client E-Mail

example@example.com

Client Gender

Client Birth Date

MonthDayYear

Client Height (inches)

Client Weight (lb's)

Body fat %

Have you ever had (Please check all that apply)

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

Occupational activity level:

Exercise

Are you currently following a structured exercise plan? If yes, please explain.

How many days do you strength train?

Do you train at home or in a gym?

What is your typical strength training routine?

What strength equipment do you have available to you?

Do you do cardiovascular exercise?

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?

What are your eating habits?

Have you ever followed a specific nutritional plan?

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

Caffeine Consumption

Do you smoke?

Include other comments regarding your Medical History

Client Medical History