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