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?