Health History Questionnaire


Note: If you would prefer to print and fill the form on paper, click below.


A) Client Demographics

* indicates a required field.

  • What is you current height?
  • What is you current weight?
  • At what weight would you or did you feel best at?
How would you characterize your current lifestyle?


Emergency Contact

B) Coronary Artery Disease (CAD) Risk Factors

  1. Are you a male older than 45 years? or a female older than 55 years?
  2. Do you have a father or brother who had a heart attack or sudden death before the age of 55?
    A mother or sister who has had a heart attack or sudden death before 65?
  3. Do you smoke? If yes, how many cigarettes per day?
  4. Do you have diabetes (or currently medicated for high blood glucose)? Do you have Prediabetes (or currently medicated for high blood glucose)?
  5. Do you have high blood pressure (or currently medicated for high blood pressure)?
  6. Do you have high cholesterol (or currently medicated for high cholesterol)?
  7. Do you lead a sedentary lifestyle?

C) Known diseases and symptoms

Known Diseases
Do you have any personal history of coronary or atherosclerotic disease (stents, bypass, etc.)?
Do you have any personal history of metabolic disease (thyroid, renal (kidney), liver?
Suggestive Symptoms

Have you been diagnosed with or exhibited symptoms of any of the following conditions?

Do you have any other non-cardiac related conditions or diseases?
Date of your last physical examination:
Would you be willing to provide us with a copy of the blood chemistry panel?

D) Injuries or Other Orthopedic Limitations

Check the areas that have been injured both recently and in the past:

Are you presently receiving physical therapy, chiropractic, or any other form of rehabilitative therapy?
May we contact your therapist?
Are you aware of any medical or other personal limitations not covered by this questionnaire, which would restrict your participation in a program of physical activity?

E) Your Health and Exercise Interests

F) Health and Fitness Objectives

Release of Liability Waiver

Because physical exercise can be strenuous and subject to risk of serious injury, we urge you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity. You agree that by participating in physical exercise, physical therapy or massage therapy activities, you do so entirely at your own risk. Additional recommendations for food supplements, or weight reduction products, are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes. You agree that you are voluntarily participating in these activities and assume all risks of injury, illness, or death.

You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a release of liability. You expressly agree to release and discharge the trainer or therapist from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer or therapist for personal injury or property damage.

If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.

Cancellation Agreement

I retain Mobile Health & Fitness to render Personal Training, Physical Therapy, and/or Massage Therapy services.

I understand that I may cancel any appointment with my therapist by giving 24 hours’ notice. I also understand that if I fail to provide the aforementioned cancellation notice, as indicated, I will be charged for the full session fee.