Client intake forms

 

Client Profile










ADDRESS:

 

FITNESS GOALS AND OBJECTIVES:  Circle all that apply 


 

PREFERRED TRAINING TIME/DAY

SPECIAL CONSIDERATIONS 

1. Has a doctor ever said you have a heart condition and that you should only do physical activity Recommended by a doctor? YesNo

2. Do you experience an irregular or racing heart rate during rest or exercise? YesNo    

3. Do you feel pain in your chest when you do physical activity? YesNo

4. Do you lose your balance because of dizziness or do you ever lose consciousness? YesNo

5. Do you have a bone or joint problem that could be made worse by a change in  your physical activity?  YesNo 

6. Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
YesNo 

7. Do you know of any other reason why you should not do physical activity?   YesNo

8. Are you over 65 and not accustomed to vigorous exercise? YesNo

9. Are you diabetic? YesNo

10. Are you pregnant?  YesNo

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