Thrive Health Concepts Health Assessment Form

Health and Fitness Assessment Form
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship
Gender

MaleFemaleOther
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
OPTIONAL - To allow me to calculate your hip/waist ratio- please state your waist circumference at smallest point in cmblanks and your hip circumference at the widest point in cmblank
Do you have any chronic illnesses or medical conditions? (e.g., diabetes, hypertension)

YesNo
If yes, please specify
Have you had any surgeries or hospitalisations in the past?

YesNo
If yes, please provide details
Are you currently taking any medications?

YesNo
If yes, please list them
Do you have any allergies? (e.g., food, medication, environmental)

YesNo
If yes, please specify
Do you smoke?

YesNo
If yes, how many cigarettes per day
Do you consume alcohol?

YesNo
If yes, please specify
Describe your diet

BalancedHigh in FatHigh in SugarVegetarian/VeganOther
How often do you exercise?

DailySeveral times a weekOnce a weekRarelyNeverOther
Please detail your exercise/training history and the struggles you've had in the past
Do any of your close relatives have any of the following conditions?

Heart DiseaseStrokeCancerDiabetesHypertensionOther
Are you currently experiencing any of the following symptoms? (Check all that apply)

HeadachesDizzinessShortness of BreathChest PainAbdominal PainJoint PainMuscle WeaknessFatigueInsomniaOther
Do you have any other health concerns or symptoms not listed above?

YesNo
If yes, please specify
How would you describe your current mental health status?

1

2

3

4

5

1 is Poor, 5 is Excellent
Are you currently experiencing any of the following? (Check all that apply)

DepressionAnxietyStressMood SwingsOther
Do you currently take any vitamins or supplements?

YesNo
If yes, please specify
Do you have any other health-related information you would like to share?
Do you have medical consent from your Doctor to take part in an exercise program?

yesno
Has your Doctor given you limitations to adhere to during exercise? Please describe below.
What is your intended goal or outcome from my coaching?
Where do you currently follow Thrive Health Concepts?

FacebookInstagramWebsiteEmail
Consent

By signing below, I acknowledge that the information provided is accurate to the best of my knowledge and I consent to its use for the purpose of my health assessment.
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Health and Fitness Assessment Form