Health Questionnaire

Name

First NameLast Name
Birth Date

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
Emergency Contact
Physician's name & contact
Occupation
Height (cm's)
Weight (kg's)
What would you like to accomplish in training?
General Health
Have you had and/or do you currently have any medical conditions or injuries? Have you had a recent surgery?
If you have injuries: When did it start? How did it start? Is it getting better or worse? What makes it worse and what makes it better?
If you have injuries: Describe the pain and location. How often is the pain present and how long does it last for?
Are you pregnant or have you given birth within the last 6 months?
Please list any medications you are taking
How does the medication affect your ability to exercise?
Do you smoke? If yes, how many per week?
Do you consume alcohol? If yes, how much per week?
How many hours do you sleep per night?
Is your job sedentary, moderately active or physically demanding?
What is your typical work schedule?
On a scale of 1-10, how would you rate your stress levels? (1 being low, 10 high)
Do you experience this stress in your work life, personal life or both?
How do you currently manage your stress?

Nutrition
On a scale of 1-10, how would you rate your current nutrition?
How many times a day do you usually eat (including snacks)?
Do you skip meals?
Are you intermittent fasting?
Do you eat breakfast?
Do you eat late at night?
What activities do you engage in while eating? (TV, reading etc...)
How man glasses of water do you consume daily?
Do you feel your energy levels drop during the day? If yes, what time?
Do you take any supplementation? If yes, please list them.
At work or school, do you usually eat out or bring food?
How may times per week do you eat out?
Do you do your own grocery shopping?
Do you do your own cooking?
Besides hunger, what other reason(s) do you eat?

BoredomSocialStressTiredDepressedHappyNervous
Do you eat past the point of fullness?
Do you eat foods high in sugar and fat?

General Health