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Tell Me About Your Goals...
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Name (Last, First)
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Contact Information
Phone Number
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Email Address
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Fill in the blanks: In 12 weeks, I want to be able to __________
In 4-6 weeks I want to be able to __________
On a scale of 1-10, how confident are you in achieving these goals?
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out of 10
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Provide some information about your health...
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Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.)
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Have you ever had any surgeries? (If yes, please explain.)
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Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? (If yes, please explain.)
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Are you currently taking any medication? (If yes, please list.)
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What is your current occupation?
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Does your occupation require extended periods of sitting?
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Does your occupation require extended periods of repetitive movements? (If yes, please explain.)
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Does your occupation require you to wear shoes with a heel (dress shoes)?
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Does your occupation cause you anxiety (mental stress)?
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Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.)
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Do you have any hobbies (reading, gardening, working on cars, etc.)? (If yes, please explain.)
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Provide some information about your current physical activities...
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Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
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Do you feel pain in your chest when you perform physical activity?
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In the past month, have you had chest pain when you are not performing any physical activity?
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Do you lose your balance because of dizziness or do you ever lose consciousness?
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Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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Do you experience pain, soreness or tightness in any of the following areas?
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Do you have any previous injuries in any of the following areas?
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Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
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Do you know of any other reason why you should not engage in physical activity?
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Do you ever feel weak, tired or sluggish?
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How many meals do you eat each day?
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Do you crave sugary foods?
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Are you happy with the way you look and feel?
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What are 2 things that you would like to change about yourself?
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On a scale of 1-10, how committed are you to reaching your goals?
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Out of 10
How many times are you currently able to train in 1 week?
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