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