Personal Training Client Profile and Health History by klutzfu58

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									          Personal Training Client Profile and Health History
                             Date:________________

Name:________________________________________ Age:______

Date of Birth:________________

Address:____________________________________________________

City, State:_________________________________ Zip Code:_________

Home Phone:_____________________ Work/Cell phone:_______________

Email Address:________________________________________________

Briefly describe what you do for a living:_____________________________

Emergency Contact Number(s):

Name:__________________________________ Phone:_______________

Name:__________________________________ Phone:_______________



                          Personal Medical Information


Are you currently under the care of a physician specialist? Yes____ or No____

If yes, what is your physician’s name?________________________________

Specialty?____________________________________________________

Please list any medications you are taking and give a reason as to why:

______________________________ ______________________________

______________________________ ______________________________

______________________________ ______________________________
                              Personal Health History
Have you ever experienced any of the following health related difficulties?
 (If yes, please give a time frame and a brief description of the incident.)

                                Yes No
Lung or Respiratory disease     ___ ___ ______________________________

Dizziness/feeling faint         ___ ___ ______________________________

High Blood Pressure             ___ ___ ______________________________

Cardiovascular disease          ___ ___ ______________________________

Diabetes                        ___ ___ ______________________________

Stroke                          ___ ___ ______________________________

Cancer                         ___ ___ ______________________________

Arthritis                      ___ ___ ______________________________

Major illness/surgery          ___ ___ ______________________________

Physical Therapy                ___ ___ ______________________________

Sendentary Lifestyle            ___ ___ ______________________________

Unable to maintain
Healthy body weight             ___ ___ ______________________________

Do you smoke?                  ___ ___ ______________________________

								
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