Welcome To Total Health Skills

Assessment

HEALTH HISTORY FORM

First Name :*

Last Name :*

Date of Birth :

Height:

Home phone no :*

Cell phone no :*

Email Address :*

Occupation :

Are you taking any medications : Yes No

Medications :

OVERALL HEALTH CONCERNS

Serious Injuries :

Pregnant :

Other Medical Issues :

Smoke? : Yes No

Alcohol? : Yes No

Caffeine? : Yes No

Alcohol Consumption per week by glass/bottle :

Caffeine Consumption per week by cup:

NUTRITION QUESTIONS

Food Allergies/Do Not Like:

How often do you eat out:

How often do you cook per week:

Taking vitamins/which ones:

FITNESS QUESTIONS

What is your current exercise routine additional to daily living:

How would you rate your fitness level:12345Five being best

Indicate the main reason why you want to begin an exercise program:

What activities do you prefer in a regular exercise program:

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