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Cart
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About
Services
Courses
Podcasts
Blog
Testimonials
Contact
Date
MM
DD
YYYY
Client Name
*
First Name
Last Name
Email Address
*
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
Age
Birthdate
*
MM
DD
YYYY
Height
Weight
Physical Activity Readiness
Date of last physical
MM
DD
YYYY
Has your doctor ever said that you have a heart condition and recommended only medically supervised activity?
Yes
No
Have you had chest pain when you were not doing physical activity?
Yes
No
Do you lose your balance due to dizziness or do you ever lose consciousness?
Yes
No
Have you experienced any shortness of breath, heart murmur, or heart racing?
Yes
No
Are you pregnant now or have you given birth in the last six months?
Yes
No
Have you had a recent surgery?
Yes
No
If you marked YES to any of the above please elaborate below.
Cardiovascular + Health History
Check any risk factors or information on the following...
Blood Pressure
Cholesterol
Diabetes
Heart Disease
Do you smoke cigarettes?
How much alcohol a week do you drink?
What prescriptions are you presently taking and why?
ORTHOPAEDIC HISTORY
Have you ever broken a bone?
If yes, where and when?
Check any problem areas.
Low Back
Upper Back
Neck
Shoulders
Elbows
Wrists
Pelvis
Knees
Ankle
Foot
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
Signed
Date
MM
DD
YYYY
EXERCISE HISTORY and GOALS
What exercise or organized sports have you done in the past?
Are you currently involved in a regular exercise program, describe your typical exercise regime?
(weights, cardio, how long per workout, how many times a week)
What are your goals in training now, any particular activity or exercise that you have always wanted to do?
(pull-up, handstand, max bench press, compete in a triathlon)
How many times a week can you work out?
What has hindered your workouts in the past?
PRESENT LIFESTYLE
Present occupation
sedentary
light
active
Stress level at work
1-10, episodic, or continual
Do you manage stress well?
Yes
No
Sleep quality and amount
Amount of air travel
Commuting time
Do you experience anxiety or depression?
NUTRITION AND WEIGHT GOALS
What is a typical daily diet for you?
Breakfast Lunch Dinner
Have you had any history of eating disorders?
(anorexia, bulimia, emotional eating)
What is your current weight?
Has there been more than a 5 lb. fluctuation of weight in the past year?
Yes
No
What things would you like to change about your body?
Thank you!
