Consultation Form

Body In Rhythm Training Consultation Form
Name

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Date of Birth
In Case of Emergency, call
Age
Gender
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.
Personal History
Have you had a prior heart attack, angina, or stroke
Do you have high blood pressure
Smoking
Alcohol
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
Have you ever worked with a trainer
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)
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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Body In Rhythm Training Consultation Form

Family History

Personal History