The purpose of this health history form is to help obtain the general background of an client's health & exercise history. It is not meant to replace your physician's expertise, diagnosis, or medical treatment. This document was created to distinguish participants who are currently not ready for exercise or physical activity. Coughlin Fitness & Results strongly advises that each client take a regular physical with their doctor or physician before starting one of our fitness programs.

* - denotes required fields
Contact Information
*Fullname:
*Address:
*City:
*State:
*Zip Code:
*Home Phone:
Work Phone:
Mobile Phone:
Email Address:
Contact Name:
Contact Phone:
Physician:
Physician Phone:
*Age:
Birth Date:	January February March April May June July August September October November December / / 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Height:
Weight:
Sex:	Male Female
Health & Exercise History
Have you ever participated in an exercise program? Yes No
If yes, please explain:
If no, what other activities do you participate in?
Are you currently taking any medications or drugs? Yes No
Medication: Condition: Dose: Medication: Condition: Dose: Medication: Condition: Dose: Medication: Condition: Dose:
Have you experienced a history of heart problems, chest pain, or stroke? Yes No
If yes, please explain:
Does your immediate family have a history of heart problems? Yes No
If yes, please explain:
Do you have increased blood pressure? Yes No
If yes, please explain:
Have you been hospitalized or had recent surgery in the past year? Yes No
If yes, please explain:
Have you experienced hernia, or any condition that may be aggravated by lifting weights? Yes No
If yes, please explain:
Are you pregnant or have you given birth within the last 3 months? Yes No
If yes, please explain:
Do you have a history of breathing or lung problems? Yes No
If yes, please explain:
Do you smoke cigarettes? Yes No
If yes, please explain:
Do you have a muscle, back, kidney, or joint disorder? Yes No
If yes, please explain:
Have you experienced an injury recently or in the past? Yes No
If yes, please explain:
Are you currently receiving physical therapy treatments? Yes No
If yes, please explain:
Do you have a diabetes or thyroid condition? Yes No
If yes, please explain:
Do you have increased blood cholesterol? Yes No
If yes, please explain:
Is there a health issue not mentioned in this questionnaire that would keep you from participating in regular exercise? Yes No
If yes, please explain: