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@rivernorthfit
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:
Sedentary
Semi-Active
Active
Extremely Active
How often do you consume alcohol?
Fitness Interests:
Former activities performed:
Nutrition - rated on scale of 1 - 5 (1 being poor):
1
2
3
4
5
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: