Body In Rhythm Training Consultation Form
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth
In Case of Emergency, call
Age
0-29
30-39
40-49
50-59
60-69
70-79
80+
Gender
Male
Female
Current Weight
Family History
An immediate family member that has heart disease, high blood pressure, high cholesterol, or has had a heart attack or stoke.
At or before age of 55
Between ages 56 to 65
After the age 65
N/A
Personal History
Have you had a prior heart attack, angina, or stroke
Yes
No
Do you have high blood pressure
Yes
No
Smoking
I currently smoke
I am a former smoker
I have never smoked
Alcohol
I drink more than 2 drinks per day
I drink less than 2 drinks per day
I do not drink at all
Medical History
Do you suffer from the flowing: Diabetes, Arthritis, Psychological Disorder (s), Asthma, Epilepsy, Back or Neck Problems, other (please specify)
Injury
Area of pain, When, Surgery, What caused it? List of each if apply.
Access to equipment
Do you have Dumbbells, Kettlebells, Cables, Bands, MedicineBalls etc?
Exercise
No activity at all in a typical week
Exercise for at least 20 minutes, 1 to 2 times per week
Exercise for at least 20 minutes, 3 times per week or more
Have you ever worked with a trainer
Yes
No
Main Goals
What in your daily life do you want to improve (ex: sportsperformance, general fitness, fat loss, pain management?)
Are you currently pregnant? If yes, what month are you currently, and have you consulted with a physician about starting an exercise program?
Please check the appropriate below for those which apply to you (past or present)
Aortic Aneurysm
History of Surgery
Cancer
Bladder Problems
Gastro/Intestinal Problems
Arthritis
Excessive Fatigue
Arrhythmia’s
Phlebitis
Musculoskeletal Disorder
Coronary Disorder
Epilepsy
Valvular Heart Disease
Irregular Heartbeats
Seizures
Thyroid Problems
Heart Murmur
Stroke
Poor Tolerance to Exercise
Broken Bones
Gout
Nervous/Emotional Problems
Skin Condition
Ulcers
Low back Problems
Kidney Disease
Anemia
Are you on any medications?
Please list name, purpose, dosage
What was the date of your last physical?
Have you ever had a treadmill stress test or other exercise test? If yes, what were the results?
I declare that the information I have given above is true and correct.
Signature
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