Tell Me About Your Goals...
(Fill out as much as you can)
Name:
(last,first)
Phone:
Email:
What are 3 things that you would like to accomplish within the next 4-6 weeks?
What are 3 things that you would like to accomplish within the next 12 weeks?
On a scale of 1-10, how confident are you in achieving these goals?
out of 10
​
You Are 25% complete!
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?
​
You Are 50% complete!
You Are 40 % complete!
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.)
​
You Are 70% complete!
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
​
In 1 week, how often can you train?