I look forward to working together! First, I’d like to get some background information from you so that I can better assist you in achieving your goals.

The following Health History Questionnaire is split into four sections:

  • Health History

  • Lifestyle

  • A “Typical” Day

  • Physical Activity & Fitness

  • Goals

Please answer these questions to the best of your ability. Please allow 15-30 minutes to fill out this form. We will discuss all of the information you provide below in person as well!

*All information will remain confidential & will not be shared with any other party.



 

Name
Name
Health History
How frequent are your bowel movements?
Lifestyle-Related
How often do you smoke?
Do you drink alcohol?
If yes, how many drinks do you consume on average per week?
Do you normally get a good night sleep? *
How many hours of sleep do you get every night (on average)?
Do you work a typical 9-5 job?
Do you commute to your job?
Do you have a sedentary job/Do you sit at a desk for work?
A "Typical" Day
Most mornings, what time do you wake up?
Most mornings, what time do you wake up?
When do you typically eat your first meal of the day?
When is the next time you eat?
When is the next time you eat?
Please provide me a few examples of a typical meal for each section below? You can be as specific or just give me general ideas of what types of meals you eat (ex 1: eggs with toast & jam, turkey sandwiches with an apple, and pasta with red sauce // ex 2: 2 fried eggs with a piece of toast & jam, turkey sandwich with lettuce, tomato & onion on wheat bread, 1 bowl of spaghetti with marinara sauce sprinkled with mozzarella cheese)
Please answer these questions to the best of your ability. If you do not know the answer to these questions, just write “I don’t know”
Physical Activity/Fitness-Related Questions
Where would you prefer to workout (feel free to choose more than one option)?
Do you own any equipment at home?
Goals
Thanks for taking the time to fill out this questionnaire-you’re almost ready to start training!! This is the first step towards a healthier you!