Health History Form

First Name

Last Name

Today' Date

Email

Phone

Birthdate

Street Address

City

Region/State/Province

Postal / Zip code

Physician Name

Physician Phone Number

Have you been told not to exercise for any reason? *

No

Yes

What reasons were you told not to exercise?

Are you currently taking any medications? *

No

Yes

What medications are you currently taking?

Please list any previous injuries that could impair your ability to exercise.

Are you in pain? If so, please list where (and cause) if known.

Do you have any of the following?

Hyperextension

High Cholesterol

Diabetes

Asthma

Heart Disease

Previous Stroke

Gastointestinal Issues

None of the above

Please list any sports-related injuries youve incurred in the past 10 years.

How would you describe your current nutritional habits?

Greate

Average

Poor

By checking this box, I agree that all the information above is accurate to the best of my knowledge.

Your Signature

Hours of operation

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