Nutrition & Health Assessment Personal Information Name: Address: City: State: Zip: Home Phone: Work Phone: E-mail: Reason for Consultation: Birth date: Age: M/F: Male Female Marital Status: Children: Height: Next Brief Medical History Please indicate (✔) whether you have or had any of the following conditions: High Blood Pressure Heart Disease or Heart Attack Diabetes High Cholesterol Level Irregular Heart Rate Chest Pain Dizziness Heart Murmur Shortness of Breath Respiratory Disease Epilepsy or Convulsions Orthopedic Conditions Osteoporosis Hernia Arthritis Thyroid Disorder Gastrointestinal Disorder Stroke Hypoglycemia Anemia Cancer Blood Disorder Lactose Intolerant Please explain above (✔) conditions: List all old or recent injuries: When was your last complete physical exam? List any recent and/or past operations and dates performed: List all Food Allergies: List all medication you are currently taking: Do you smoke? Yes No If Yes, Frequency: Do you drink? Yes No If Yes, Frequency: How many times a week do you exercise? What kind of exercise do you do? Have you ever been on a diet before? Yes No If Yes, describe: Do you use any special diet products? Yes No If Yes, describe: Loss of Consciousness/Heart Attack/Stroke? YES NO If Yes, how long ago? Back Next Family History Do any of your blood relatives (brothers, sisters, parents, grandparents, aunts, uncles, etc.) have or have had: Heart Attacks Diabetes Heart Operation Epilepsy High Blood Pressure Congenital Heart Disease High Cholesterol Other Back Next Description of Daily Schedule Wake-up Morning: Afternoon: Evening: Workouts Morning: Afternoon: Evening: Breakfast Morning: Afternoon: Evening: Lunch Morning: Afternoon: Evening: Dinner Morning: Afternoon: Evening: Snacks Morning: Afternoon: Evening: Bedtime Morning: Afternoon: Evening: Notes Morning: Afternoon: Evening: Back Next Waiver I, the undersigned, have read, understand, and have answered the above health/medical survey questions fully and truthfully. I am aware of my responsibility to consult with my personal physician regarding my clearance to engage in strenuous exercise and/or a nutritional support program. I do hereby intend to be legally bound for myself and waive release of any and all rights and claims for damages I may have against the participating training facility, and the fitness trainer/certified fitness nutrition specialist administering this program as well as the program creators themselves or anyone in connection with them for any and all injuries suffered while following the training and/or nutrition program provided to me. I also understand and agree to the no refund policy stated above. Client Signature: Print Client Name: Date: Back Submit Assessment
