Client History Form

Trainer *

Trainer's Email Address *

First Name *

Last Name *

Email *

Date *

Date of Birth *

Age

Weight (lbs) *

lbs

Goal weight (lbs) *

lbs

Current body composition

%

Primary Goal *

Please specify *

If other, please specify

Expected time to reach goal *

weeks

Target Competition Date *

Desired Category *

Exercise equipment available to client *

Fitness classes

Home workouts

Outdoor cardio (i.e. run or bike)

Commercial gym

Crossfit

Has client previously tried to reach goal? *

Yes

No

Please elaborate on the efforts

Please also indicate any reasons for why you may not have been successful with prior attempts

Is client currently following a fitness program? *

Yes

No

Please describe current workout routine

What is typical/preferred time to workout? *

Early morning (before breakfast)

Mid morning

Lunch/mid-day

Afternoon

Evening/after work

Night time

Who does client work out with? *

How long are workouts? *

Ideal # workouts/week? *

Weight training experience *

Rate comfort level with the following lifts

1 = novice; 5 = expert

Date of last physical exam/physician's visit

Does client suffer from any of the following?

Arthritis

Ankle pain

Carpal tunnel/wrist pain

Unspecified chronic pain

Herniated disks

Hip pain

Knee pain

Low back pain

Rotator cuff injury

Has client ever been diagnosed with any of the following?

Ashtma

Atherosclerosis

Cancer

Diabetes

Epilepsy

Gastrointestinal disorders

Gout

Heart disease

High cholesterol

Hypertension

Osteoporosis

Stroke

Thyroid dysfunction

For all issues checked, please elaborate

List all medications or herbal supplements/vitamins (and dosages) currently used

List all allergies (environmental, drug and food based)

Does client smoke? *

Yes

No

Packs per week?

packs

Do you consume canabis? *

Yes

No

Times per week?

packs

Does client drink alcohol? *

Yes

No

How many drinks per week?

Does client do shift work? *

Yes

No

If yes, please elaborate on work hours

Additional comments

If there is any other information you'd like to communicate to your trainer, please indicate it above.

Rate comfort level with the following lifts

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