Training Intake Form Contact Information Name Permanent Home Address City State Zip Code Home Phone Work Phone Pager Cell E-mail Address Emergency Contacts Primary Physician Physician Phone Emergency Contact Phone Relationship Marital Status Spouse/Partners Name Biometric & Health Information Age Height Weight Profession Medications Sport Performance/Enhancement Supplements, Vitamins, Health Herbs, Weight Loss/Gain Pills, Powders, Liquids, and solids taken Lifestyle On a scale from 1-5 what is your daily stress level, and why? (1 being lowest) 12345 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? If yes, how much per day? YesNo How often do you consume alcohol, and how much? Level of activity now: SedentarySemi-ActiveActiveExtremely Active Fitness Experience & Goals What are your two top fitness goals, and why? Current workout program Workout Frequency/week Minutes Per Session Fitness Interests Former activities performed Nutrition - rated on scale of 1 - 5 (1 being poor) 12345 Are you willing to change your eating habits? YesNoMaybe Medical History Last Physical/Check-up Is your doctor aware of desire to become more physically active? YesNo History of heart disease, chest pain or discomfort, heart murmur or arrhythmia? YesNo History of coronary artery disease (CAD), Stroke? YesNo Family history of heart disease (Parents, Grandparents, Siblings)? YesNo If yes, specify relationship and age at time of event or diagnosis High blood pressure or taking Anti-hypertension medications? YesNo If on medication, specify drug and type of drug Borderline or high serum blood cholesterol (>200 MG/DL)? YesNo History of breathing or lung problems (asthma or chronic bronchitis)? YesNo Severe shortness of breath during daily activities? YesNo Any sleeping disorders or trouble having a good night's rest? YesNo Muscle, Joint, and/or back pain or disorder of arthritis or prior injury? YesNo 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? YesNo Surgery or hospitalization within the last 12 months? (If yes, specify incident). YesNo Surgery or hospitalization planned (in or out patient procedure) within next 30 days? (If yes, please specify) YesNo Excessive accumulation of body fat? YesNo History of diabetes (Non-insulin Dependent Diabetes, Insulin Dependent Diabetes)? Thyroid condition (hypo/hyperthyroid) Seizure activity? YesNo Pregnancy now or within the last 3 months? YesNo If pregnant, when are you expecting? Any difficulty with exertion or advice from MD not to exercise or limit activities? YesNo Any chronic or prolonged illness or condition? YesNo Any other condition not addressed above that may be aggravated by an increase in physical activity? YesNo If Yes, please explain Were you Referred? YesNo If yes, By Whom? How did you find me? GoogleOther Search EngineTwitterFacebookLinkedInOther If "Other", please specify