CLIENT INTAKE FORM
Name and Age
Preferred Method of Contact
Emergency Contact, Name and Phone #
Cleared for Exercise by Physician?
Please Select
Yes
Not yet
How did you hear about me? If online, what did you search for?
MEDICAL HISTORY
Any existing injuries or medical conditions?
Do you experience any pains or discomforts that make it difficult to exercise, perform daily tasks, and/or assume specific positions?
Do you currently take any medications or supplements including vitamins (OTC or prescription)? If so, what are they and what are they for?
Have you ever had any major surgeries or injuries? Please provide approximate dates and describe how they currently affect you.
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Please check all that apply:
Wrist pain with any activities that position them in full extension, like planks and push ups
Exercise induced migraines
Plantar fasciitis
Hip pain
Knee pain
Ankle pain
Lower back pain
Upper back pain
Neck pain
A clotting disorder
Scoliosis
Symptomatic hernia
Diabetic ulcers on feet
Vertigo
Eating disorder
Diabetes
Recurrent seizures
Pathologic heart murmur
Anemia
Multiple Sclerosis
Thyroid disease
Vascular disease
Uncontrolled or exercise-induced asthma
COPD (Chronic Bronchitis and/or Emphysema)
Osteoporosis
Accidental urine leakage with sudden movements (coughing, laughing, sneezing) or exercise that you would like to address with training
Heart attack*
Stroke*
A fall or multiple falls*
*Please provide dates for any falls, heart attack(s), and/or stroke(s):
How do the items you checked above impact your ability to exercise?
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Can you get on and off the floor relatively easily?
Please Select
Yes
No
EXERCISE HISTORY
Have you tried anything in the past to change your habits, health, diet, and/or body?
Please Select
yes
no
If Yes, what have you tried that worked well for you?
What have you tried that didn't work well for you?
Do you have negative feelings toward, or have you ever had any bad experience with a physical activity program? If yes, please explain:
Do you currently participate in any exercise, sports, or recreational activities? If Yes, please explain
If No, when did you last participate in any exercise, sports, or recreational activities, and why did you stop?
GOALS
What is your primary reason for embarking on this training program?
What would success look like for you?
Primary goal:
Secondary/Long-term goals:
From here on out, what do you want your exercise routine to be like (#days, intensity, type)?
Do you own any type of exercise equipment? Please list in detail:
Anything you want me to keep in mind as your coach (what motivates you, what you like/don't like, etc)?
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