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HPS North
Home
Philosophy
Services
CPR
HPS North
The Future of Fitness is Wellness
Health History Questionnaire
Before personal training instruction can begin, we need to know a little more about you! All questions contained in this questionnaire are strictly confidential.
Name
*
First Name
Last Name
Sex
*
--
Male
Female
Date of Birth
*
Phone
*
Email Address
*
Emergency Contact (include relationship)
*
Emergency Contact Phone
*
Injuries/Surgeries/Diagnosis of Disease (include date of diagnosis and any medications)
Exercise
*
--
Sedentary (no exercise)
Mild exercise (i.e. climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e. work or recreation, less than 4x/week for 30 min.)
Regular vigorous exercise (i.e. work or recreation 4x/week for 30 min.)
Are You On a Specific Diet (i.e. vegetarian, low calorie, etc)?
*
No
Yes
If Yes, What Kind of Diet (i.e. vegetarian, low calorie, etc.)?
Number of Meals You Eat in an Average Day
--
1
2
3
4
5
5+
Family Health History (include any significant health problems in your father, mother, and/or children)
Resting Blood Pressure
Resting Heart Rate
Body Fat %
Weight
Thank you!
