Training Intake Form

Referred? Yes No
 By Whom?

Name:

Age:

Height:

Permanent Home Address:

City:

State:

Zip Code:

Weight:

Home Phone:

Work Phone:

Pager:

Cell:

E-mail Address:

Primary Physician:

Phone:

Emergency Contact:

Phone:

Profession:

Relationship:

Marital Status:

Spouse/Partners Name:

Sport Performance/Enhancement Supplements, Vitamins, Health Herbs,
Weight Loss/Gain Pills, Powders, Liquids, and solids taken:


Medications:


What are your two top fitness goals, and why?


On a scale from 1-5 what is your daily stress level, and why? (1 being lowest)


How much time do you set aside for social activities or recreation?


How many hours per week on the average do you work?


Do you smoke? How much per day?


Current workout program:


Workout Frequency/week Minutes Per Session:


Level of activity now:

How often do you consume alcohol?


Fitness Interests:


Former activities performed:


Nutrition - rated on scale of 1 - 5 (1 being poor):

Are you willing to change your eating habits?


Medical History

Last Physical/Check-up:

Is MD aware of desire to become more physically active? Yes    No

History of heart disease, chest pain or discomfort, heart murmur or arrhythmia? Yes    No

History of coronary artery disease (CAD), Stroke? Yes    No

Family history of heart disease (Parents, Grandparents, Siblings)? Yes    No

If yes, specify age at time of event or diagnosis:

High blood pressure or taking Anti-hypertension medications? Yes    No

If on medication, specify drug and type of drug:

Borderline or high serum blood cholesterol (>200 MG/DL)? Yes    No

History of breathing or lung problems (asthma or chronic bronchitis)? Yes    No

Severe shortness of breath during daily activities? Yes    No

Any sleeping disorders or trouble having a good night's rest? Yes    No

Muscle, Joint, and/or back pain or disorder of arthritis or prior injury? Yes    No

Specify details, such as what might aggravate the condition, which side of body, pain scale, causes, etc.


History of hernia or any condition that lifting weights could aggravate? Yes    No

Surgery or hospitalization within the last 12 months? (If yes, specify incident). Yes    No


Surgery or hospitalization planned (in or out patient procedure) within next 30 days? (If yes, please specify) Yes    No



Excessive accumulation of body fat? Yes    No

History of diabetes (Non-insulin Dependent Diabetes, Insulin Dependent Diabetes)?
Thyroid condition (hypo/hyperthyroid) Seizure activity? Yes    No
Details:

Pregnancy now or within the last 3 months? Yes    No

If pregnant, when are you expecting?

Any difficulty with exertion or advice from MD not to exercise or limit activities? Yes    No

Any chronic or prolonged illness or condition? Yes    No


Any other condition not addressed above that may be aggravated by an increase in physical activity? Yes    No

Specify: