Healthy Habits Personal Trainers Medical History Form

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HEALTHY HABITS PERSONAL TRAINERS
MEDICAL HISTORY FORM
First & Last Name:________________________________________________________
Date of Birth:_________________________________Age:________________________
Address:________________________________________________________________
Phone Numbers:
Home _____________, Cell______________Work________________
Level of Activity (check one):
( ) Sedentary ( ) Mildly Active ( ) Active ( ) Very Active
Notes on Activity:
Measurements:
Height____ Weight___ Body Fat %___ Body Fat %____ Body Fat Percentage
Goal_____Arm________ Thigh________ Calf_________ Chest___ Waist___
Daily Meals:
Breakfast________________________________________________________________
Lunch__________________________________________________________________
Dinner__________________________________________________________________
Snacks__________________________________________________________________
Diets:
Have you ever used any diet shakes/pills? ______________________________________
If yes, what was the result?__________________________________________________
Joints:
Have you ever been diagnosed with joint or soft tissue problems?
Yes ( ) No ( )
If yes, explain____________________________________________________________
Do you have any problems with
your:
Please circle and if yes, explain
Upper back______________________________________________________________
Lower back______________________________________________________________
Neck___________________________________________________________________
Shoulders_______________________________________________________________
Wrists__________________________________________________________________
Hips____________________________________________________________________
Knees Ankles____________________________________________________________

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