| Today's Date: | |
| Full Name: | |
| Date of Birth: | |
| Full Address: |
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| Phone: | |
| Email address: | |
| Emergency Contact Name: | |
| Emergency Contact Number: | |
| Doctor Name: | |
| Doctor Number: | |
Check the space to the left of the question if
answer is "yes" |
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Are you currently being treated for high blood
pressure? | |
If you know your average blood pressure, please
enter: | |
| Please check all diagnoses that apply: |
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Has a doctor imposed any activity restrictions?
If so, please describe: |
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Please select any medications you are currently
using: |
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Are you a cigarette smoker? If so, how many per
day? | |
| Please rate your daily stress level(select one): |
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| Do you drink alcoholic beverages? | |
| How many units of alcohol do you consume/week: | |
| Dietary Habits Please select all that apply: |
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On average, how many times a week do you
exercise? | |
On average, how long do you exercise per
session? | |
On a scale of 1-10, how intense is your typical
workout? | |
Which of the following Activities are part of
your routine? |
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| indicate duration in minutes: | |
Please indicate your personal health and fitness
goals: (Check the box) |
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Please tell us more about your exercise patterns
and goals: |
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| Exercise history: |
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| Needs: |
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| Wants: |
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| Activity Preferences: |
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| Barriers to Success: |
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| Motivation Level: | |
| Confidence Level: | |
List your concrete commitments to Reach Your
Goals: |
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| How did you here about us? | |
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