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Be the Solution Fitness Coaching Intake Form
Please take a minute to fill out this form. This allows me to know your health history and goals we will be working on together. We will go over this form together at your consultation for more details and anything you wish to further explain.
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Email
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Your email
Name:
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Your answer
Birthday:
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DD
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YYYY
Age:
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Your answer
Occupation:
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Your answer
Address:
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Your answer
Cell Phone:
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Your answer
Emergency Contact:
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Your answer
Has a doctor ever said you have a heart condition and recommended only medically supervised activity?
Yes
No
Clear selection
Do you have chest pain brought on by physical activity?
Yes
No
Clear selection
Do you tend to lose consciousness or fall over as a result of dizziness?
Yes
No
Clear selection
Has a doctor ever recommended medication for your blood pressure, cholesterol, or a heart condition?
Yes
No
Clear selection
Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
Yes
No
Clear selection
Are you aware of any other physical reason against your exercising without medical supervision?
Yes
No
Clear selection
Are you over the age of 65 and not accustomed to vigorous exercise?
Yes
No
Clear selection
If you have answered YES to any of the above questions, Please answer the following: Have you consulted your physician about increasing your physical activity and/or performing a fitness assessment?
Yes
No
Clear selection
Date of Consult:
Your answer
If you have answered NO to the above question will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?
Yes
No
Clear selection
Are you comfortable getting up and down off the floor?
Yes
No
Clear selection
Have you had any surgery with in the past year or two? If yes please explain below:
Your answer
Check below if you currently have or have had any of the following conditions:
Angina (chest pain)
Heart Condition
High Blood Pressure
Shortness of Breath
High Cholesterol
Cancer
Asthma uncontrolled
Asthma controlled
Stroke
Thyroid Malfunction
Arthritis of Any Kind
Pulmonary Embolism
Anemia
Hernia
Other:
Explain any checked:
Your answer
List any muscuskeletal /joint issues / injuries (e.g. Arthritic joints, spinal conditions, knee problems, shoulder problems):
Your answer
Please indicate below any medications that you are taking and their purpose:
Your answer
Do you smoke?
Yes
No
Clear selection
Do you drink?
Never
Occasionally
Socially
More then once or twice a week
Clear selection
What are your primary fitness goals?
Your answer
What are you currently doing to reach your fitness goals?
Your answer
How important is reaching this goal to you?
Not that Important
1
2
3
4
5
6
7
8
9
10
Extremely Important
Clear selection
What type of hobbies / activities are you involved in?
Your answer
What are your biggest obstacles?
Your answer
What does your nutrition currently look like? What does this mean to you?
Your answer
Do you certify that you have read and answered all of the above questions truthfully and to the best of your knowledge? Initial and date below:
Your answer
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