• General Patient Information

• Client Gender*
  Male Female
• Phone Number
   - Area Code Phone Number
• Client Name*
  First Name Last Name
• Client Birth Date*
  January February March April May June July August September October November December Month 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 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 E-Mail*

• 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:
  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
  
• 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: