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 * Weight loss Physique competition Muscle building Applicant Testing Athletic Performance Health improvements Other Please specify * Triathlon Distance running Martial arts Track Swimming Rowing Hockey Cycling Other If other, please specify Expected time to reach goal * weeks Target Competition Date * Desired Category * Bodybuilding Physique Figure Fitness Model Bikini 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? * Solo Workout buddy Personal Trainer Small group Sports team Fitness class How long are workouts? * < 20 minutes 20 - 40 minutes 40 - 60 minutes 60 - 90 minutes > 90 minutes Ideal # workouts/week? * 2 3 4 5 or more Weight training experience * None 0 - 6 month 6 - 12 months 1 -3 years > 3 years Rate comfort level with the following lifts 1 = novice; 5 = expert Barbell squat 1 2 3 4 5 Deadlift 1 2 3 4 5 Bench press 1 2 3 4 5 Chin up/pull up 1 2 3 4 5 Power clean 1 2 3 4 5 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 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.
