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Name:	(First) (Last)
Contact Information
Phone:	(Home) (Work)
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Current Health Conditions

High Blood Pressure: Yes No      If yes... Current reading: Date of last reading High Cholesterol: Yes No      If yes... Current reading: Date of last reading Diabetes: Yes No      If yes... What type? Type 1 Type 2 Date of last reading Heart Disease: Yes No      If yes... Describe: Do you smoke? Yes No Height: Weight: Age: If you are under the age of 18 you must have parental consent for training. Please list any other known medical conditions you currently have or have been treated for in the past five years. Please list any current or past injuries. Please write a brief summary of your previous or current exercise history. Nutritional Habits How many ounces of water do you drink a day? How many times a week do you eat out? Please describe your goals and if there is a target date you wish to accomplish them by. Privacy Statement We respect your privacy. We do not sell or give away any information regarding our clients to other parties. All information given to us is kept in strict confidence.