www.HealthyWithLaura.com 

Your Health History Form

 

Please print this page, fill it out and mail to:

Laura Fisher

562 West 261st Street

Riverdale, NY 10471

 

Name_______________________________Phone(Hm/Cell)_______________________

 

Address________________________________City_____________St_______________

 

Zip______________Employer_______________________Type of Work_____________

 

Dob________________Height____________Weight______________Sex(M/F)_____

 

In Case of Emergency Contact___________________Phone_______________________

 

Date of last physical Exam_________Blood Pressure________Resting HR___________

 

Training HR__________  E-mail ____________________________________________

 

Please check the following items as each is applicable to your health.  This information will help to design your fitness program.  Be sure to circle yes or no.

 

!. Medical Background

    Please circle yes or no.

 

Yes   No  High blood pressure? If yes, describe__________________________________

 

Yes   No   Heart problem? If yes, describe______________________________________

 

Yes   No   Is there a history of heart disease in the family? (i.e. heart attacks, stroke, etc.)

 

Yes   No   Have you ever experienced a heart palpitation/irregular heart beat?

 

Yes   No   Have you ever had chest pains?

 

Yes   No   Have you ever experienced dizziness or fainting spells?

 

Yes   No   Have you ever had problems with breathing or been diagnosed as asthmatic?

 

Yes   No   Do you have allergies or hay fever?  If yes, describe_____________________

 

Yes   No   Do you get short of breath from mild exertion?

 

Yes   No   Do you have epilepsy?

 

Yes   No   Are you diabetic or have a family history or diabetes? If yes, describe ________________________________________________________________________

 

Yes   No   Have you ever been diagnosed as being hypoglycemic?

 

Yes   No   Do you experience any neck pain?  If yes, describe______________________

 

Yes   No   Do you suffer from any back pain?  If yes, describe______________________

Yes   No   Do you suffer from arthritis, bursitis, tendonitis or carpal tunnel syndrome?

 

Yes   No   Have you ever had a hernia?  If yes, describe___________________________

 

Yes   No   Have you ever suffered a joint injury?  If yes, describe___________________

 

Yes   No   Do you have high cholesterol?  If yes, describe_________________________

 

Yes   No   Do you smoke?  If yes, how many packs or cigarettes per day? ____________

 

Yes   No   Are you an ex-smoker?  If yes describe________________________________

 

Yes   No   Do you fast?  If yes, describe________________________________________

 

Yes   No   Are you under a doctorís care for a current illness?  If yes, describe_________________________________________________________________

 

Yes   No   Have you been recently hospitalized?  If yes, describe_________________________________________________________________

 

Yes   No   Are you currently using medication that may affect your physical performance?  If yes, describe_______________________________________________

 

Yes   No   Do you take allergy medication?  If yes, describe________________________

 

Yes   No   If applicable, are you currently, or were you recently pregnant?  If yes, describe_________________________________________________________________

 

NOTE:  If you answered yes to any of the questions above, please see your physician prior to beginning your training program.

 

  1. Physical Activity Profile

 

Please check the following items that best describes your current daily activity level.  This information will help me to understand your current ability to exercise.  Be sure to circle yes or no.

 

Yes   No   Are you active or inactive on your work? Please describe ________________________________________________________________________

 

Yes   No   Are you exercising regularly now? If yes, describe_________________________________________________________________

 

Yes   No   Are you overweight?  If yes, how much weight would you like to lose? ___________________________________________________________________

 

LEAVE FOR ME

 

  1. Heart Rate (Monitor/Resting 30 sec.)

______________________________________________________________

 

  1. Body fat % ________________________________________________________

 

  1. Sit and Reach Test __________________________________________________

 

  1. Measurements

 

  1. Buttocks/Hips ______________________________________________________

 

  1. Thigh_____________________________________________________________

 

  1. Calf______________________________________________________________

 

  1. Waist_____________________________________________________________

 

  1. Neck (Men)________________________________________________________

 

  1. Arm______________________________________________________________

 

  1. Chest (Optional)____________________________________________________

 

  1. Bodyweight________________________________________________________

 


 

                                PERSONAL TRAINING AGREEMENT

 

Recommendation

 

It is strongly recommended that you get a physical examination by your physician every year

 

Overview of Current Condition

 

After reviewing your health history and analyzing your current level of physical activity, we will explain the results and provide you with an exercise program.  Therefore, it is strongly recommended that you ask questions about your program.

 

As a participant of the Personal Training Program, you will be provided with ongoing evaluations to determine your progress and to adjust you program accordingly.

 

Before we start your training program, we would like to point out a few important details. 

 

 

  1. Notify your trainer at least 24 hours in advance of any necessary schedule changes.  In the event of a no-show or unauthorized schedule change you are responsible for payment of that session.
  2. Be 5-10 minutes early for your appointment and dressed in your exercise clothes ready to exercise.  This courtesy is appreciated to help keep appointments from overlapping.  The amount of time you are late will be deducted from the training session.
  3. Each session will be approximately one hour.  Any time you request beyond the initial hour there will be an additional charge.
  4. For best results, training 2-3 times per week ensures you will achieve your goals.

 

Consent

 

I am voluntarily participating in the Personal Training Program which has been explained to me verbally and in writing.  I am aware of my own current level of health and physical condition.  I am also aware that participating in any exercise training program has inherent risks of injury.  I agree that I will contact my physician.  If I need any medical attention.

 

 

Signature                                                                                        Date

 

 

Personal Trainerís Signature                                                          Date