Client intake.
Personal Information.
Name:
First name
Last name
Date of birth:
/
Month
/
Day
Year
Date
Gender:
Male
Female
Weight:
Height:
Contact Information.
Email address:
example@example.com
Phone number:
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lifestyle Questionnaire.
Q1. What are your current fitness/training goals?
Q2. What is your current training routine? (Frequency/Type/Session/Length/Intensity)
Q3. What is your availability for training sessions?
Q4. Do you have any particular exercise or equipment likes or dislikes?
Q5. How would you describe your lifestyle? (Nutrition/Sleep/Stress/Work/Smoking/Alcohol Intake)
Health Status & Medical information.
Number of hours you work per week:
What does your job require you to do:
Sit at a desk
Lifting heavy loads
Standing
Walking
Driving
Please list any medications you have taken the last 6 months:
Please list any medical conditions & include any injuries in the last six months:
Have you had any prior surgeries, if yes please explain:
Do you have any current pain or injuries that could prevent you from exercising:
PAR-Q.
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
2. Do you feel pain in your chest when you do physical activity?
3. In the past month have you had chest pain when you were not doing physical activity?
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
5. Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity?
6. Is your doctor currently prescribing drugs (for example water pills) for a blood pressure or heart condition?
Signature:
Date:
/
Month
/
Day
Year
Date
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