Information/Assessment Form
Individual Information
Date
/
Day
/
Month
Year
Date
Name
First Name
Last Name
Phone Number
Alt. Phone Number
Email
example@example.com
Birth Date (DD/MM/YY)
/
Day
/
Month
Year
Date
Male
Female
Other Identification/Pronoun
Street Address
City
Postal Code
Emergency Contact Information
Name
Relationship
Contact Number
Please enter a valid phone number.
General Health History
1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Yes
No
2. Do you feel pain in your chest when you perform physical activity?
Yes
No
3. In the past month, have you had chest pain when you are not performing any physical activity?
Yes
No
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Yes
No
7. Do you know of ANY other reason why you should NOT engage in physical activity?
Yes
No
If so, Explain?
Occupation
Does your occupation require extended periods of sitting?
Yes
No
Does your occupation require repetitive movements?
Yes
No
If so, Explain?
Does your occupation require shoes with heels?
Yes
No
Does your occupation cause you anxiety (mental stress)?
Yes
No
Do you partake in recreational activities? (sports/exercise/other)
Yes
No
If so, Explain
Do you have hobbies? (reading/gardening/other)
Yes
No
If so, Explaine
Medical History
Have you ever had any pain or injuries? (Ankle, Knee, Hip, Hip, Back, Shoulder, Wrist, Etc.)
Yes
No
If so, Explain
Have you ever had any surgeries?
Yes
No
If so, Explain
Have you been diagnosed with any of the following? (Select all that apply)
Cardiovascular disease
Hypertension
High cholesterol
Stroke/blood lipid disorder
Lung/breathing disorder
Obesity
Diabetes mellitus
Cancer
Are you taking any of the following medication types? (Select all that apply)
Beta-blockers
Calcium-channel blockers
Nitrates
Diuretics
Bronchodilators
Vasodilators
Antidepressants
Please explain
Assessment
Age
Weight (lbs)
Height (Feet)
Height (Inches)
General Diet:
Never
-
Sometimes
-
All the time
Eating "junk" food
Eating Fast food
Eating Meat
Eating Veggies
Eating Fruits
Eating Dairy Products
Drinking caffeine
Drinking carbonated beverages
Drink juices (sugary)
Drinking water
Approximately how much water do you drink daily? (cups)
General Diet
Never
-
Sometimes
-
All the time
High carb (bread) intake
Protein powder use
Supplements (vitamins)
Please explain which ones
Enjoyment Scale
1
2
3
4
5
Cardio/circuit (1) vs. Weights/machines (5)
Lower body (1) vs. Upper body (5)
Gym workouts (1) vs. Home workouts (5)
Equipment based (1) vs. Body weight based (5)
Machines (1) vs. Free-weights (5)
Duplicated routines (1) vs. Regular change-up (5)
Motivation/Accountability
Never
-
Sometimes
-
All the time
I want to workout
I want to lose weight
I want to gain muscle
I want to change my health
I want to improve my energy
I want to improve my flexibility
Goal Setting
First Goal
Second Goal
Third Goal
Strengths
Weaknesses
Additional Information and/or Questions
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