AtHomeBeFIT
Functional. Intelligent. Training.
Health History Questionnaire
Lisa Knighton
ACE Certified Personal Trainer * Brookbush Institute Trainee * Orthopedic Exercise
Specialist * Fitness Nutrition Specialist * PhysicalMind Trained Pilates Matwork
Instructor M.S., University of Georgia
Los Ranchos de Albuquerque, NM 87107
Name
______________________________________________________________________
_______
Date ___________________ Age______ Birthday, with year: ____________________
Gender ______
Physician’s Name_________________________________ Physician’s Phone
__________________
Person to contact in case of emergency:
Name_________________________________________________________
Phone________________________
Are you taking any medications, supplements, or drugs? If so, please list medication,
dose, and reason.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
________________________________________________________
Does your physician know you are participating in this exercise program?
______________________________________________________________________
______________
Describe any physical activity you do somewhat regularly.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________
Do you now have, or have you had in the past (please feel free to use the space on the
back):
1. History of heart problems, chest pain, or stroke
AtHomeBeFIT
Functional. Intelligent. Training.
Health History Questionnaire
Lisa Knighton
ACE Certified Personal Trainer * Brookbush Institute Trainee * Orthopedic Exercise
Specialist * Fitness Nutrition Specialist * PhysicalMind Trained Pilates Matwork
Instructor M.S., University of Georgia
Los Ranchos de Albuquerque, NM 87107
2. Elevated blood pressure
3. Any chronic illness or condition
4. Difficulty with physical exercise
5. Advice from physician not to exercise
6. Recent surgery (last 12 months)
7. Pregnancy (now or within last 3 months)
8. History of breathing or lung problems
9. Muscle, joint, or back disorder
10. Any previous injury still affecting you
11. Diabetes or metabolic syndrome
12. Thyroid condition
13. Cigarette smoking habit
AtHomeBeFIT
Functional. Intelligent. Training.
Health History Questionnaire
Lisa Knighton
ACE Certified Personal Trainer * Brookbush Institute Trainee * Orthopedic Exercise
Specialist * Fitness Nutrition Specialist * PhysicalMind Trained Pilates Matwork
Instructor M.S., University of Georgia
Los Ranchos de Albuquerque, NM 87107
14. Obesity [body mass index (BMI) ≥30 kg/m
2
]
15. Elevated blood cholesterol
16. History of heart problems in immediate family
17. Hernia, or any condition that may be aggravated by lifting weights or other physical
activity
Is there anything else you’d like for me to know about your current health?