Revive Form

Name
Birthday

MonthDayYear
Date
Age
Phone Number

Area CodePhone Number
Email Address
example@example.com
Emergency Contact

Please fill out information for a person to contact incase of an emergency.
Name
Relationship
Phone

Area CodePhone Number
Alternate Phone

Phone Number
Exercise Habits:

Fill out honestly.
1. In the past 6 months, how often have you engaged in physical activity? (Select One)

Always (7 days a week)Regularly (3–4x/week)Semi regularly (1–2x/week)Sporadically (1–2x/month)
2. Please explain your current exercise regime or activities performed in the past
3. Please list any cardio vascular activities that you enjoy
4. Please list any strength training exercises that you enjoy
5. What are your personal barriers for exercising or sticking to a program?
6. How much time do you plan spending on your workout program?

blank minute/day

blank day/week
Exercise Goals:
1. Why have you decided to begin or improve your exercise program?
2. Why have you decided to come to class?
3. Specifically describe what you would like to accomplish in your workout sessions.
4. Specifically describe what you would like to accomplish through your fitness program during the next:
a. Month Goal:
b. 6 Months Goal:
c. Year Goal:
Personal History:

In order to design a safe and effective fitness program, it is important that you complete the following Health History. It is crucial that you answer all the questions honestly and to the best of your ability. (Please be advised that all information is kept strictly confidential. Check the appropriate response. Read all the questions thoroughly.)
1. Has your doctor ever told you that you have heart problems?

YesNo
2. Has your doctor ever told you that you have high blood pressure?

YesNo
3. Have you ever had stroke or heart attack?

YesNo
4. Have you ever had pain in your chest that concerned you?

YesNo
5. Do you ever feel faint or have dizzy spells?

YesNo
6. Have you had surgery in the last six months?

YesNo
Click the appropriate condition(s) that apply to you below:
Diabetes:

YesNo
Epilepsy:

YesNo
Blood Pressure:

YesNo
Asthma:

YesNo
Arthritis:

YesNo
High Cholesterol:

YesNo
Heart:

YesNo
Pregnancy:

YesNo
Osteoporosis:

YesNo
Have you injured or have chronic pain in the following areas?

Please Check Yes or No
Neck:

YesNo
Shoulders:

YesNo
Elbows:

YesNo
Hips:

YesNo
Wrists:

YesNo
Knees:

YesNo
If yes to any, please explain
Medication Information

Please List Any Medication For Health Information
Are you currently taking any medications?

YesNo
If you checked yes, please list medications, dosage and for what condition.
Medication
Dosage
Condition
Medication
Condition
Medication
Condition
Please write any known reactions to exercise your medication can have on you.
Substance Information
Do you smoke?

YesNo
Do you use alochol?

YesNo
Are there any other reasons (health or personal) that may limit or prevent you from exercising?
*Please be advised that certain health restrictions may require you to obtain medical clearance from your physician before training can begin.

"I can do everything through him who gives me strength." Philippians 4:13
Should be Empty:

Emergency Contact

Exercise Habits:

Exercise Goals:

Personal History:

Click the appropriate condition(s) that apply to you below:

Have you injured or have chronic pain in the following areas?

Medication Information

Substance Information