Information & Health History This form is a complete profile of your personal contact information as well as current physical condition and goals you wish to achieve. We very much appreciate you taking the time complete this form as fully as possible. Date:* MM slash DD slash YYYY First Name:*Last Name:*Email:* A copy of this form will be sent to this email address.Phone:*Date of Birth:*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Street Address:City:State /Province/Region:Zip/Postal Code:Have you ever retained a personal trainer or coach in the past? Yes No If YES, approximate dates - Please describe your experience and if it met your expectations?EMERGENCY CONTACT:Contact:*Phone:*Relationship:HEALTH HISTORY:Did you receive a medical clearance from your physician prior to beginning your exercise program?* Yes No Has your doctor ever advised you against exercise?* Yes No If YES, please explain why.Have you undergone any surgeries in the past year?* Yes No If YES, please describe.Do you have any areas of your body that limit you during exercise? Yes No If YES, please describe.Is this limitation constant or does it "come and go?" It is constant It comes and goes What makes it better?What makes it worse?PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING: Heart Problems Chest Pain High Blood Pressure Asthma / Inhaler Fainting Hypoglycemia Arthritis Chronic Illness Smoking Muscle / Joint Problems Neck / Back Injuries Diabetes Thyroid Conditiion Pregnant Breathing Problems I HAVE NO MEDICAL CONDITIONS. Other, not listed above. Please describe fully.LONG TERM GOALS AND OBJECTIVES FOR YOU AND YOUR BODY:Goal #1:Goal #2:Goal #3:Goal #4:Specific Body Areas: (ie; arms, legs, abs, glutes, etc.)Specific Body Area #1:Rank 1-10: (1 = "Not Happy" to 10 = "Happy")12345678910Specific Body Area #2:Rank 1-10: (1 = "Not Happy" to 10 = "Happy")12345678910Specific Body Area #3:Rank 1-10: (1 = "Not Happy" to 10 = "Happy")12345678910Specific Body Area #4:Rank 1-10: (1 = "Not Happy" to 10 = "Happy")12345678910Captcha Δ