Date
Date
Client Name *
Client Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Birthdate *
Birthdate
Physical Activity Readiness
Date of last physical
Date of last physical
Has your doctor ever said that you have a heart condition and recommended only medically supervised activity?
Have you had chest pain when you were not doing physical activity?
Do you lose your balance due to dizziness or do you ever lose consciousness?
Have you experienced any shortness of breath, heart murmur, or heart racing?
Are you pregnant now or have you given birth in the last six months?
Have you had a recent surgery?
Cardiovascular + Health History
Check any risk factors or information on the following...
ORTHOPAEDIC HISTORY
If yes, where and when?
Check any problem areas.
FITNESS PARTICIPATION AGREEMENT
I have voluntarily chosen to participate in physical activity. I have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent or restrict me from participation in any exercise program given. I understand that by signing this agreement that I hereby waive and release Catherine Cowey in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation. I affirm that I have read and understand this document and I wish to participate in physical activities
Date
Date
EXERCISE HISTORY and GOALS
(weights, cardio, how long per workout, how many times a week)
(pull-up, handstand, max bench press, compete in a triathlon)
PRESENT LIFESTYLE
Present occupation
1-10, episodic, or continual
Do you manage stress well?
NUTRITION AND WEIGHT GOALS
Breakfast Lunch Dinner
(anorexia, bulimia, emotional eating)
Has there been more than a 5 lb. fluctuation of weight in the past year?