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Training Intake Form
Permanent Home Address:
Sport Performance/Enhancement Supplements, Vitamins, Health Herbs,
Weight Loss/Gain Pills, Powders, Liquids, and solids taken:
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?
Former activities performed:
Nutrition - rated on scale of 1 - 5 (1 being poor):
Are you willing to change your eating habits?
Is MD aware of desire to become more physically active?
History of heart disease, chest pain or discomfort, heart murmur or arrhythmia?
History of coronary artery disease (CAD), Stroke?
Family history of heart disease (Parents, Grandparents, Siblings)?
If yes, specify age at time of event or diagnosis:
High blood pressure or taking Anti-hypertension medications?
If on medication, specify drug and type of drug:
Borderline or high serum blood cholesterol (>200 MG/DL)?
History of breathing or lung problems (asthma or chronic bronchitis)?
Severe shortness of breath during daily activities?
Any sleeping disorders or trouble having a good night's rest?
Muscle, Joint, and/or back pain or disorder of arthritis or prior injury?
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?
Surgery or hospitalization within the last 12 months? (If yes, specify incident).
Surgery or hospitalization planned (in or out patient procedure) within next 30 days? (If yes, please specify)
Excessive accumulation of body fat?
History of diabetes (Non-insulin Dependent Diabetes, Insulin Dependent Diabetes)?
Thyroid condition (hypo/hyperthyroid) Seizure activity?
Pregnancy now or within the last 3 months?
If pregnant, when are you expecting?
Any difficulty with exertion or advice from MD not to exercise or limit activities?
Any chronic or prolonged illness or condition?
Any other condition not addressed above that may be aggravated by an increase in physical activity?