Patient Intake - TrainOn

Personal

Family History

Medical

Diet

Exercise

Injuries

Consent

Personal Information

Name

Surname

Date of Birth

Occupation

Cell Number

Next of Kin

Details

Family History (Health & Medical)

Family Medical History

Medical Conditions

Disease/Ailment

Receiving Treatment?

Treatment Details

Doctor/Physician Name

Do you smoke?

Sleep patterns (1-10)

Self-prescribed medication

Allergies

Eating Habits

Wake-up time

Meals (First to last meal details)

Supplements

Exercise & Training

Current Training Schedule

Goals

Athlete?

Sport

Coach Name

Coach Contact

Past Training & Reasons for Change

Surgeries & Injuries

Injury List

Surgery List

Doctor Name

Doctor Contact

Consent & Payment

Guardian's Consent (if needed)

Payment Consent

Payment Method

Patient Intake Form