Client Medical History Form

Gathers a client's medical background, exercise habits, and eating patterns before starting a personalized training program.

Use this template

Client Name

Nombre

Apellido

Phone Number

Client E-Mail

Client Gender

Client Birth Date

Client Height (inches)

Client Weight (lb's)

Body fat %

Have you ever had (Please check all that apply)

Any family history of the above, If yes, please explain:

Any other medical problems/concerns not already identified?

Please list any injuries and Dates of Each

Please list your Current Medications/supplements

Occupational activity level:

Exercise

Yes No

Are you currently following a structured exercise plan? If yes, please explain.

How many days do you strength train?

0 days 1-2 days 3-4 days 5+ days

Do you train at home or in a gym?

At Home At the Gym Both

What is your typical strength training routine?

What strength equipment do you have available to you?

Do you do cardiovascular exercise?

Yes No

How many days do you do cardio AND How many minutes each day?

If yes, What is your typical weekly cardiovascular routine?

What are your eating habits?

Healthy Moderate Unhealthy Irregular

Have you ever followed a specific nutritional plan?

Yes No

If yes, Who created it for you and what did it consist of?

What were your results?

What is a typical weekday and weekend of nutrition for you?

What foods do you like?

What foods do you dislike?

Alcohol Consumption

None Occasional Moderate Frequent

Caffeine Consumption

None Occasional Moderate Frequent

Do you smoke?

Yes No

Include other comments regarding your Medical History

Client Medical History Form

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