Thrive Health Concepts Health Assessment Form

Health and Fitness Assessment Form
Name

First NameLast Name
Date of birth

DayMonthYear
Date
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Relationship
Gender

Other
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: 0000 000-000.
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)
If yes, please specify
Have you had any surgeries or hospitalisations in the past?
If yes, please provide details
Are you currently taking any medications?
If yes, please list them
Do you have any allergies? (e.g., food, medication, environmental)
If yes, please specify
Do you smoke?
If yes, how many cigarettes per day
Do you consume alcohol?
If yes, please specify
Describe your diet

Other
How often do you exercise?

Other
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?

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

Other
Do you have any other health concerns or symptoms not listed above?
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)

Other
Do you currently take any vitamins or supplements?
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?
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?
Disclaimer:

If you have answered no to all of the above questions and you are confident that you have no other concerns with your health then you may proceed to participate in physical activity. If you have answered yes to any of the questions above or are unsure, please seek a referral from your GP or allied health professional before commencing physical activity.

I believe to the best of my knowledge that all of the information I have provided on this tool is accurate. In the case that my medical condition changes over the course of my training I will inform my trainer and fill out a new exercise pre-screening questionnaire.
Signature
Date Signed

MonthDayYear
Date
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Health and Fitness Assessment Form