This document contains a 34-question health history and lifestyle worksheet for a new client. It collects information about the client's contact details, schedule, medical history, current physical activity level and goals, perceived barriers to exercise, stress levels, and access to fitness equipment to help design a safe and effective personalized exercise program.

1. Health History and Lifestyle Worksheet
Name:___________________________________________________________ T-shirt size ______M F
Address: _________________________________________________ Age:____ Birthdate: _______________________
_________________________________________________________ Sex: ____ Height: _________________________
email:_________________________________________________________
Weight:_________________________________
Phone: Home ______________________________________________Business/Cell: _____________________________
Physician’s Name: _________________________________________ Phone: ___________________________________
Emergency Contact-Name/Relationship: _________________________________________________________________
1. Which days and times are best for you?
Time
Monday __________ Start date: _____________
Tuesday __________ How often: _____________
Wednesday __________ Forms Completed: Please attach
Thursday __________ Health History Y N
Friday __________ Consent Y N
Saturday __________ Billing Contract Y N
Medical Release Y N
2. Please check if applicable
Client Family If Yes, Describe
Y N Y N
Diabetes __ __ __ __ ___________________________________
High Blood Pressure __ __ __ __ ___________________________________
High Cholesterol __ __ __ __ ___________________________________
Smoke or use tobacco products __ __ __ __ ___________________________________
Angina/Chest Pain __ __ __ __ ___________________________________
Heart Murmur __ __ __ __ ___________________________________
Irregular Heart Beats __ __ __ __ ___________________________________
Abnormal Electrocardiogram __ __ __ __ ___________________________________
Rheumatic Fever __ __ __ __ ___________________________________
Thrombophebitis __ __ __ __ ___________________________________
Respiratory Infections __ __ __ __ ___________________________________
Asthma __ __ __ __ ___________________________________
Embolism __ __ __ __ ___________________________________
Aneurysm __ __ __ __ ___________________________________
Stroke __ __ __ __ ___________________________________
Valve Disease __ __ __ __ ___________________________________
Heart Attack __ __ __ __ ___________________________________
3. Do you have any of the following conditions that may limit your physical activity? (Check all that apply.)
__Ankle/Foot Injury __Bone Fracture __Shoulder/Clavicle Injury __Arthritis
__Low Back Pain __Wrist/Hand Injury __Arm/Elbow Injury __Knee/Thigh Injury
__Hip/Pelvic Injury __Calcium Deposits __Nerve Damage __Tennis Elbow
__Upper Back Injury __Head/Neck Injury __ Pregnancy (Pre or Postnatal) __Other
If other, please explain: _________________________________________________________________________

2. 4. Please list any surgeries or medical procedures you have had:
Procedure Date Physician
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. Has your physician ever advised you against exercise? __ Yes __ No
6. Are you presently receiving physical therapy? __ Yes __ No
7. Are you presently taking any medications (including vitamins, minerals and other herbal supplements)?
__ Yes __ No If yes, please list names and dosages of each: __________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
8. Are you involved in an exercise program at the present time? __ Yes __ No
If yes, please describe the program and frequency: ____________________________________________________
_____________________________________________________________________________________________
9. In the past year, how often have you been engaged in physical activity?
__ Competitively (More than 4 times a week with scheduled competition)
__ Regularly (3 to 4 times/week)
__ Semiregularly (1 to 2 times/week)
__ Sporadic (1 to 2 times/month)
10. What types of physical activity do you consider “fun”? ______________________________________________
11. What types of physical activity do you NOT enjoy participating in? ___________________________________
12. What are your personal barriers or reasons for not exercising? _______________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
13. What kind of physical activity have you been successful with in the past that you liked and participated in
regularly? ____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
14. Do you consider yourself overweight? __ Yes __ No
If yes, how do you think your weight affects your daily activities?________________________________________
_____________________________________________________________________________________________
15. Do you feel any family, friends, or co-workers have negative feelings (i.e. disapproval, resentment) toward
your efforts at physical activity or weight loss? __ Yes __ No
If yes, who and why? ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
16. Is your significant other or any closer friends involved in regular physical activity? __ Yes __ No
17. What is your present occupation? ________________________________________________________________
18. How would you rate the amount of physical activity you do at work or in you daily activities?
__ Very Little __ Little __ Moderate __ Active __ Very Active

3. 19. If you work, how would you rate the stress level of your job?
__ Little __ Moderate __Stressful
20. How would you rate the stress level of your daily life (outside of work)?
__ Little __ Moderate __ Stressful
21. What types of things make you feel stressed? ______________________________________________________
22. How do you normally deal with your stress? ______________________________________________________
23. When exercising, including climbing stairs, do you ever experience any of the following? (check all that apply)
__ Chest Pains __ Shortness of Breath __ Pressure over the Heart __ A Tired-out Feeling
__ Leg Aches __ Dizziness
24. Have you ever had a stress test? __ Yes __ No
If so, date of your most recent test: _________________ Physician who performed the test: _______________
Results: __ Normal __ Abnormal
25. What was your weight one year ago? _____ Five years ago? _____ Ten years ago? ______
26. Do you follow any special diet at the present time (including non-medical diets)? __ Yes __ No
If so, what type?
__ Low Cholesterol/Low Fat __ Low Salt __ Reduced Calorie __ Liquid Diet __ Other
If other, please specify: _________________________________________________________________________
27. How many meals and/or snacks do you have per day? _______________________________________________
28. Do you drink alcohol? __ Yes __ No If yes, how much and how often? ______________________________
29. Do you feel you eat healthy “most of the time”? __ Yes __ No
If yes or no, briefly explain why? _________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
30. What are your personal exercise program goals?
__ Weight Control/Loss __ Staying in Shape __ Stress Reduction __ Increasing Strength
__ Cardiovascular Conditioning __ Competition __Other
If other, please describe: ________________________________________________________________________
31. Specifically describe what you would like to accomplish through your fitness program during the next:
1 month _____________________________________________________________________________________
4 months _____________________________________________________________________________________
6 months _____________________________________________________________________________________
1 year ________________________________________________________________________________________
32. How long are you planning on investing and committing to using a personal trainer? ____________________
33. What type of fitness equipment do you presently have access to?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

4. 34. Any additional information or comments you think your trainer needs to know before you begin an exercise
program?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________