GENERAL FITNESS & WELLNESS ASSESSMENT
Complete this pre-session intake to share your fitness and wellness goals, history, and acknowledgments before your first visit.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Emergency Contact
General Health & Medical History
Do you have or have you ever had any of the following? (Check all that apply)
Heart disease
High blood pressure
Diabetes
Asthma or lung conditions
Arthritis or joint pain
Back pain or injury
Recent surgery (past 12 months)
Pregnancy (current or recent)
None of the above
Other (please specify)
If you checked any condition above or have other health concerns, please provide details:
Are you currently taking any medications?
Yes
No
If yes, please list your medications:
Do you smoke or use tobacco products?
Yes
No
Former user
Do you consume alcohol?
Yes
No
Physical Activity & Lifestyle
How would you describe your current level of physical activity?
Very active (5+ days/week)
Moderately active (2-4 days/week)
Lightly active (1 day/week or less)
Not currently active
What types of physical activities do you currently participate in?
Are there any activities you would like to avoid?
On average, how many hours of sleep do you get per night?
Please Select
Less than 5
5-6
7-8
More than 8
Do you have any dietary restrictions or preferences?
Goals & Expectations
What are your main fitness and wellness goals?
What do you hope to accomplish in your sessions at Leading Fitness?
Is there anything else you would like us to know?
Acknowledgment & Consent
Signature
*
Date:
Submit Assessment
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