Client History

Name__________________		Date_____________
		
Address: 	Street___________________
City_________________ State______ Zip Code
	     	Phone Number_________________

Date of Birth____________		Age________
Sex  M  F
Height_____		Weight______

Cholesterol Levels		Total_____		
HDL_____		LDL____

Do you currently exercise?     	Y	N
	What type? ______________________
 	How often? ______________________
Have you ever participated in a regular physical activity?	Y	N
When? ___________________	
Where? __________________

Please fill out the following as completely as possible:

Please list ALL medication(s) you are currently taking including vitamins and herbs so that we can adjust your program as necessary:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

Have you fallen in the past 2 years?				Y	N
When? _____________
Do you ever use an assistive device? (i.e. walker, cane) 	Y	N
Has one ever been recommended to you?			Y	N

Please circle yes (Y) or no (N) to indicate if you have or have ever had the following:

Heart Disease			Y	N
Heart Attack			Y	N
Angioplasty			Y	N		When? ____________
Bypass Surgery			Y	N		When? ____________
Femoral Bypass Surgery	Y	N		When? ____________
Uncontrolled Angina		Y	N		
High Cholesterol			Y	N
Diabetes				Y	N	
Do you take insulin?	Y	N
Have you participated in a Diabetes education program?	
Y	N
Joint Pain				Y	N	
Location______________________________________________
Frequency_______________________________________
Joint Replacements
Location______________________________________________
Date(s)_______________________________________________
Cancer
Location____________________________________________
Date_______________________________________________
Are you still receiving treatment?				Y	N
What type of treatment? ___________________________________
Fibromyalgia			Y	N			
Chronic Fatigue syndrome	Y	N
Urinary Incontinence			Y	N	
Depression					Y	N
Anxiety					Y	N
Loss of Vision				Y	N	
How compensated  _________
Loss of Hearing				Y	N	
How compensated  _________
Surgeries					Y	N
Date/Explain _____________________________________________
Stroke					Y	N
Date________________
“Mini” Stroke (TIA)			Y	N
Date________________
Parkinson’s Disease			Y	N
Other Neurological Disorders	Y	N	Explain________________________
Chronic Bronchitis			Y	N
COPD					Y	N
Asthma					Y	N
Lung Disease				Y	N
Attention Deficit Disorder		Y	N
Osteoporosis				Y	N
Arthritis					Y	N
Broken/Fractured Bones	 	Y	N
Location(s)/Date(s)_____________________________________
Signature________________________       Date______________________