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Health History

Corrective lenses
Dentures
Hearing aid
Medical devices/prosthetics/implants, describe
See
Hear
Taste
Smell
Feel hot/cold sensations
Fatigue
Shortness of breath
Insomnia
Constipation
Chronic pain/inflammation
Nausea
Headaches
Disinterest in eating
Dizziness
Diarrhoea
Itching/rash

Medical History

Arthritis
Allergies/hayfever
Asthma
Alcoholism
Alzheimer’s disease
Autoimmune disease
Blood pressure problems
Bronchitis
Cancer
Chronic fatigue syndrome
Carpal tunnel syndrome
Cholesterol, elevated
Circulatory problems
Colitis
Dental problems
Depression
Diabetes
Diverticular disease
Drug addiction
Eating disorder
Epilepsy
Emphysema
Eyes, ears, nose, throat problems
Environmental sensitivities
Fibromyalgia
Food intolerance
Gastoesophageal reflux disease
Genetic disorder
Glaucoma
Gout
Heart disease
Infection, chronic
Inflammatory bowel disease
Irritable bowel syndrome
Kidney or bladder disease
Learning disabilities
Liver or gallbladder disease(stones)
Mental illness
Mental retardation
Migraine headaches
Neurological problems (parkinsons’ paralysis)
Sinus problems
Stroke
Thyroid trouble
Obesity
Osteoporosis
Pneumonia
Sexually transmitted disease
Seasonal affective disorder
Skin problems
Tuberculosis
Ulcer
Urinary tract infection
Varicose veins
Other

Medical (Men)

BPH
Prostate cancer
Decreased sex drive
Infertility
STD
Other

Medical (Women)

Menstrual irregularities
Endometriosis
Infertility
Fibrocystic breasts
Fibroids/ovarian cysts
PMS
Breast cancer
Pelvic inflammatory disease
Vaginal infections
Decreased sex drive
STD
Other
days

Family Health History (parents and siblings)

Arthritis
Asthma
Alcoholism
Alzheimer’s disease
Cancer
Depression
Diabetes
Drug addiction
Eating disorder
Genetic disorder
Glaucoma
Heart disease
Infertility
Learning disabilities
Mental illness
Mental retardation
Migraine headaches
Neurological disorders (Parkinson’s, paralysis)
Obesity
Osteoporosis
Stroke
Suicide

Health Habits

Tobacco
/day
/day
Alcohol
/week
/week
/week
Caffeine
day
day
/day
Other sources
/day

Exercise

5 – 7 days per week
3 -4 days per week
1 -2 days per week
45 minutes or more duration per workout
30 – 45 minutes duration per workout
Less than 30 minutes

Nutrition & Diet

Mixed food diet (animal and Vegetable sources)
Vegetarian
Vegan
Salt restriction
Fat restriction
Starch/carbohydrate restriction
Total calorie restriction

Food frequency

Eating Habits

Skip breakfast
Two meals/day
One meal/day
Graze (small frequent meals)
Food rotation
Eat constantly whether hungry or not
Generally eat on the run

Performance Training Center does

Strength, Power and Performance Conditioning.

Comprehensive Structural Assessments and Program Designs.

Corrective and Restorative Exercise.

Nutrition

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

619-284-2510

martin@performcenter.com
Content copyright 2014. Performance Training Center. All rights reserved.
Results will differ from individuals based on their physical capabilities and effort applied.