Personal Training & Nutrition Intake

Name

Sex

Male

Female

Date

Birthdate

Height

Weight

If you re paying by credit card Name on the card

Card Number

Exp. Date

Amount over or under Weight

Blood Pressure

Pulse

Do you wish to consult

For a check-up

For a particular reason

For a particular concern with comprehensive appointment and health program

Do you feel you are basically healthy ?

Yes

What are your primary health concerns ?

Family Health History

Member	Age if living	State of Health	Age at death	Cause of death or poor health concerns
Father
Mother
Brothers
Sisters
Children

About yourself

Work:

Check One:				Single	Married	Widow(ed)	Divorced
Live with:				Family	Alone	Other

Do you smoke Tobacco ?	Amount	How Long ?
If stopped, how long since you quit?

Do you use caffeine ?	Amount	How Long ?
If stopped, how long since you quit?

Do you use recreational drugs ?	Amount	How Long ?
If stopped, how long since you quit?

Past History

Serious illnesses as a child: (Check appropriate one(s))

Rheumatic fever	Kidney trouble	Prolonged Fever
Heart Trouble

Serious illnesses as an adult

Allergies:

Medicines

Others

Operations/ Injuries:

	When ?
	When ?
	When ?

Have you ever been in the hospital for other reasons ? (Please indicate when and why ?)

Has your weight changed in the past year?	Yes No
If yes, how much?		Current weight ?
Weight 1 year ago:(approx.)		Weight 5 years ago:(approx.)

For Women

For Men
Lumps in groin area or just above and side to the penis	Yes No
Has the quality of your orgasm or force of release diminished?	Yes No
Troubles concerning erection or ejaculation?	Yes No
Prostatitis	Yes No

Please use this space to write in any other important health considerations you may have. The more specific, yet descriptive, your information is the more we will be able to help you.

For all clients

Performance Training Center does

Strength, Power and Performance Conditioning.

Comprehensive Structural Assessments and Program Designs.

Corrective and Restorative Exercise.

Nutrition

Diabetes	Tuberculosis	Allergy	Ulcers
Heart Disease	Liver Diseases	Asthma	Migraines
High Blood Pressure	Kidney Disease	Cancer	Arthritis
Convulsions	Lung Problems

Excessive flows	Yes No	Spotting between periods	Yes No
Pain / cramps during period	Yes No
Blood clots during periods	Yes No	If yes,color
Sharp pain in ovaries?	Yes No	If yes,which side?
Lumps in	Breast Armpit Groin area
Hysterectomy	Yes No	If yes,when?
Have you taken birth control pills?	Yes No	For how long ?
If you have since stopped taking birth control pills, when did you stop ?
Have you worn an IUD ?	Yes No	If yes, for how long?
If you no longer wear an IUD , when did you stop ?

Schedule Your Appointment : Call or Text 619-284-2510

Personal Training & Nutrition Intake

Family Health History

Check Disease(s) Known To Have Occurred in the Family

About yourself

Past History

Serious illnesses as a child: (Check appropriate one(s))

Performance Training Center does

440 Upas Street. Unit 104
San Diego. CA, 92103

619-284-2510

martin@performcenter.com

Have you had or do you have any of the following ?
Fever, Chills, Night sweats	Yes No	Blood in bowel movements	Yes No
Severe or frequent headaches	Yes No	Diarrhea	Yes No
Periods of unconsciousness	Yes No	Constipation	Yes No
Complete or partial blindness	Yes No	Alternating Diarrhea and constipation	Yes No
Frequent dizzy spells	Yes No	Frequent indigestion and gas	Yes No
Hearing trouble	Yes No	Ulcer of stomach	Yes No
Eye trouble	Yes No	Burning when you urinate	Yes No
Do you feel anxious	Yes No	Blood in urine	Yes No
Depressed or irritable ?	Yes No	Need to urinate frequently	Yes No
Trouble dealing with stress	Yes No	Urinate during the night	Yes No
Hay fever or sinus trouble	Yes No	Kidney or bladder stones	Yes No
Goiter or thyroid trouble	Yes No	Protein or albumin in urine	Yes No
Asthma	Yes No	Trouble starting urine stream	Yes No
Cough	Yes No	Urinary infection	Yes No
Mucous in chest or bronchial area	Yes No	Venereal disease or Herpes	Yes No
Shortness of breath	Yes No	Diabetes or sugar in urine	Yes No
Coughed up blood	Yes No	Hypoglycemia	Yes No
High blood pressure	Yes No	Arthritis, Bursitis, Rheumatism	Yes No
Have you ever had Jaundice, Hepatitis, or mono	Yes No	Nervous breakdown	Yes No
Do you awaken at night out of breath ?	Yes No	Skin rashes	Yes No
Fast, irregular, or slow pulse	Yes No	Is your appetite good ?	Yes No
Pain in chest	Yes No	Do you exercise atleast three times/week?	Yes No
Allergies	Yes No	Do you sleep well?	Yes No
Varicose veins	Yes No	Do you feel rested in the morning ?	Yes No
Frequent colds or flu	Yes No	Do you feel tired after eating ?	Yes No
Vomit blood	Yes No	Tired and diminished energy during the day ?	Yes No
Recent change in bowel habits	Yes No	Swollen lymph glands ?	Yes No
Black bowel movements	Yes No

Schedule Your Appointment : Call or Text 619-284-2510

Personal Training & Nutrition Intake

Family Health History

Check Disease(s) Known To Have Occurred in the Family

About yourself

Past History

Serious illnesses as a child: (Check appropriate one(s))

Performance Training Center does

440 Upas Street. Unit 104 San Diego. CA, 92103

619-284-2510

martin@performcenter.com

440 Upas Street. Unit 104
San Diego. CA, 92103