MIKE STEWART FITNESS
www.mikestewartfitness.com
5909 Fairdale Lane #3 * Houston TX 77057
Phone: (713) 785-5126 * Email: Admin@mikestewartfitness.com
HEALTH QUESTIONNAIRE
This Health Questionnaire is designed to provide as much information as
possible about your past and current health history. The objective is to critically
examine your health history in order to actively engage you on what you can or cannot do
in terms of resistance (weight) training and body-weight strength (cardiovascular)
training. Our primary objective is your safety. Please be as honest and complete in
your answers so that we can tailor your program to your current health condition.
OBJECTIVE.
Name: _________________________________________________________________
Marital Status: ____ Married ____ Single. Sex: _____ Male ___ Female. Age: _____
Address: ________________________________________________________________
Home Phone: ________________________ / Cell Phone: ________________________
Occupation: ______________________________ Date of Birth: ___________________
Physician: _______________________________________________________________
Office Phone: ____________________________________________________________
Email: __________________________________________________________________
1.
CURRENT PHYSICIANS DIAGNOSIS.
Have you ever had or do you currently have any of the
following current diagnosed conditions? Please check mark each one:
_____ Arthritis
_____ Broken bones
_____ Chronic cough
_____ Dislocation (bone)
_____ Kidney problems
_____ Measles (German)
_____ Asthma
_____ Cancer
_____ Convulsions
_____ Heart Disease
_____ Malaria
_____ Seizures
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_____ Back trouble
_____ Chicken Pox
_____ Diabetes
_____ High Blood Pressure
_____ Measles (red)
_____ Scarlet fever
_____ Shortness of breath
_____ Tuberculosis
_____ Sinusitis
_____ Weight issues
_____ Stomach problems
If you have marked any condition, please explain:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________ .
2. CURRENT PHYSICAL PROBLEMS. Has your physical activity been restricted in the past five
(5) years due to any stress related problems? _____ Yes
_____ No. If you have
answered YES, please explain:
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________ .
3. MEDICATION. Are you currently taking medication? _____Yes
_____ No. If so,
please explain what type of medication and if it would restrict you from resistance
training (weight lifting) or body-weight strength training (cardiovascular) training:
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________ .
4. YOUR PHYSICIAN. Are you currently under the care of a physician, chiropractor, or other
health care professional for any reason? _____ Yes
_____ No. If so, please explain:
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________ .
5. ALLERGIES. Please list any allergies you have:
________________________________________________________________________
_______________________________________________________________________ .
6. PERSONAL QUESTIONS. In order for our personal training sessions to be effective (to gain
muscle, lose weight or both), please be honest in your answer to the following questions:
Has your doctor ever said that your blood pressure was too high? _____ Yes _____ No
Has your doctor ever told you that you have a bone or joint problem
That has been or could be made worse by exercise?
_____ Yes _____ No
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Are you over the age of 65?
_____ Yes _____ No
Are you accustomed to vigorous exercise?
_____ Yes _____ No
Have you ever experienced chest pain associated with exercise?
_____ Yes _____ No
Are you currently under a doctor’s prescription for mental health
medication (Wellbutrin, Lexapro, Xanex, etc)?
Is work extremely stressful?
_____ Yes _____ No
_____ Yes _____ No
Is there any reason not mentioned within this Health Questionnaire
Why you should not follow a regular exercise program?
_____ Yes _____ No
7. FAMILY HISTORY. Do you have a family history of any of the following conditions?
Heart disease, Hypertension, Gout, Abnormal EKG, Asthma, Heart Attack,
Cardiovascular Disease, High Cholesterol, Angina, Diabetes, Other Heart Condition(s).
If yes, please explain:
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________ .
8.
SMOKING.
Do you currently smoke?
_____ Yes
_____ No.
9. MUSCOSKELETAL (MUSCLE / BONE) PROBLEMS. Please explain or describe any past or current
muscoskeletal conditions have incurred such as muscle pulls, sprains, fractures, surgery,
back pain or general discomfort:
Head / neck _____________________________________________________________
Upper back ______________________________________________________________
Shoulder / clavicle ________________________________________________________
Arm / elbow _____________________________________________________________
Wrist / hand _____________________________________________________________
Lower back ______________________________________________________________
Hip / pelvis ______________________________________________________________
Thigh / knee _____________________________________________________________
Lower leg / ankle / foot ____________________________________________________
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10. NUTRITION. Are you on any specific food / nutritional plan at this time? _____ Yes
_____ No. If so, explain:
________________________________________________________________________
_______________________________________________________________________ .
11. SUPPLEMENTS. Do you take nutritional supplements? _____ Yes _____ No. If so,
please explain:
________________________________________________________________________
_______________________________________________________________________ .
12. WEIGHT. Have you experienced a recent weight gain or loss that seemed abnormal? If
so, please explain:
________________________________________________________________________
_______________________________________________________________________ .
13.
ALCOHOL.
Do you currently drink alcoholic beverages?
_____ Yes
_____ No
14. EXERCISE. Do you currently exercise?
_____ Yes
_____ No. If so, please
explain:
________________________________________________________________________
_______________________________________________________________________ .
15.
STRESS LEVEL.
I would currently say my stress level is:
_____ Extremely high due to __________________________________________ .
_____ High due to various reasons.
_____ About normal.
_____ Normal.
_____ No stress or very little.
_____ None.
16.
EMERGENCY.
In the event of an emergency, please contact:
_____________________________________________
Name
_____________________________________________
Address
_____________________________________________
Home, Work or Cell Phone
_____________________________________________
Relationship
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17.
SIGNATURE.
Please sign below:
________________________________________________________________________
Client Name (printed)
_______________________________________________________________________
Client Name (signature)
________________________________________________________________________
Personal Trainer (printed) Michael W. (Mick) Stewart, BST(I), PT
________________________________________________________________________
Personal Trainer (signature) Michael W. (Mick) Stewart, BST(I), PT
Mike Stewart Fitness (MSF)
Health Questionnaire, V.2
Updated 7-9-2011
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MIKE STEWART FITNESS
www.mikestewartfitness.com
5909 Fairdale Lane #3 * Houston Texas 77057
Phone: (713) 785-5126 * Email: Admin@mikestewartfitness.com
or MichaelWStewart@yahoo.com.
INFORMED CONSENT FORM
This Informed Consent Form is designed to advise the client / customer of the risks
associated with resistance (weight) training and body-weight strength (cardiovascular) training.
Our primary objective is your safety.
OBJECTIVE.
Participation in a regular program of rigorous, physical activity (weight
lifting, bodybuilding or cardiovascular (body-weight strength) training) has been shown to
produce positive changes in a number of organ systems for overall body health and wellness.
These changes include increased work capacity, improved cardiovascular efficiency, and
increased muscular strength, flexibility, power and endurance. I recognize that exercise carries
some risk do the musculoskeletal system (sprains, strains, etc.) and the cardioresporatory
system (dizziness, discomfort in breathing, heart attack). I hereby certify that I know of no
medical problem (except those noted below) that would increase my risk of illness and injury as a
result of participation in a regular exercise program.
BENEFITS AND RISKS.
I understand that I will undergo initial testing and evaluation to
determine my current physical fitness status. The testing will consist of completing the:
TESTING AND EVALUATION.



Health Questionnaire
Health and Wellness Interview, and
Taking a Body-weight Strength Training (BST) test (pushups, pull-ups).
I further understand that such screening is intended to provide Mike Stewart Fitness (MSF) and
its Personal Trainers, Instructors and Officers with essential information used in the development
of individual fitness programs. I understand that my individual results will be made available
only to me. I also understand that the testing is not intended to replace any other medical test or
the services of my physician. I will be provided a copy of all test results. I may share the results
with whomever I please, including my personal physician. By signing this consent form I
understand that I am personally responsible for my actions during my tenure at Mike Stewart
Fitness (MSF) and that I waive the responsibility of Mike Stewart Fitness (MSF) and its officers
if I should incur any injury as a result of my negligence.
Signed: _________________________________________________________________
Client Name
Witness: ________________________________________________________________
Michael W. (Mick) Stewart, BST(I), PT
Date: ___________________________________________________________________
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