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Health History Form / General Exercise Program

The following questions are meant to give us a general overview of your current and past physical health which will aid in building a personalized health/fitness program designed specifically for you. 

   **This form is to be submitted before using Totally Sound Fitness, Inc.'s services.

Please Note:  All information is confidential and used only by Totally Sound Fitness, Inc to assist in building a personalized health and fitness program.  See Privacy Statement

* Required Fields

First Name*   Last Name*  
Home Phone*
(000-000-0000)		   Work/Alternate Phone  
Sex*   Age*  
Emergency Contact Person*   Phone*  
Email*  
Cardio-Respiratory History
Heart disease now? Fainting?
Heart disease in the past? Asthma?
Heart murmurs or prolapsed? Shortness of breath with exercise?
Mitral value Allergies, on medication?
Please explain
Yes answers:
Coronary Risk Factors (check any that apply)
History of high blood pressure - Current Blood Pressure
Elevated total cholesterol - Current Level
Cigarette smoking - Past    Present           #Daily
Abnormal EKG  
Family history of heart disease                  Relation to you
Diabetes - Family    Self   Insulin Dependent  
Over weight  - Number of pounds over your ideal weight
Muscular History
Current muscle injuries
Past muscle injuries
Muscular weakness now
Pain with exercise
Bone-Joint History
Diagnosed with osteoporosis or lost height?    
Joint replacement? Which joints?
Current bone or joint injuries/illness?    
Past bone or joint injuries/illness?    
Arthritis pain?    
Knee weakness, injury, surgery Which knee?
Back pain    
Please explain
Yes answers:
Have you been diagnosed with:
Disk injury?
Nerve Injury?
Arthritis in the spine?
Please explain
Yes answers:
Pregnancy or postpartum?
Recent surgeries (within 12 months)
Do you have a medical condition or symptoms not mentioned previously?
List medications you are taking and what condition each is for
Medication Condition
What regular physical activity do you do?
How often?

 SOUND BODY & HEALTH
TOTALLY SOUND FITNESS
Totally Sound Fitness, Inc.
Personalized Fitness Training Programs and Nutrition Counseling.

Personal Fitness Training at its best!
Please note: All information collected is confidential and used only by Totally Sound Fitness, Inc. to assist in building a personalized health and fitness program.

  privacy statement


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Totally Sound Fitness, Inc, serving the Greater Seattle, Bellevue, Redmond, Kirkland, Issaquah and Eastside areas. Personal fitness training, nutritional counseling, customized one on one exercise workouts by an ACE certified professional personal fitness trainer.
One on One personal fitness training at its best!

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