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Happy Sweaty Life
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Client Intake
Client Intake
Step
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General Information
Name
*
Email
*
Phone
*
Gender
*
-- Select --
Female
Male
Other
Date of Birth
*
Month
Day
Year
Height
*
Weight
*
# of hours worked per week
*
-- Select --
Less than 20
21-40
41-60
Over 60
More than 25% of the time at your job is spent: (check all that apply)
*
Sitting at desk
Lifting
Standing
Walking
Driving
Medical Questionnaire
Has a doctor ever said you have a heart condition and recommended only medically supervised activity?
*
Yes
No
Do you have chest pain brought on by physical activity?
*
Yes
No
Do you tend to lose consciousness or fall over as a result of dizziness?
*
Yes
No
Has a doctor ever recommended medication for blood pressure or heart condition?
*
Yes
No
Do you have bone or joint problems that could be aggravated by proposed physical acitivity?
*
Yes
No
Are you aware, through your own experiences or a doctor's advice of any other physica reason against your excercising without medical supervision?
*
Yes
No
Are you over the age of 65 and not accustomed to vigorous exercise?
*
Yes
No
Current Medical Information
Date of last physical exam?
*
Month
Day
Year
Check all medicines prescribed in the past 6 months:
*
Blood thinner
Epilepsy medication
Nitroglycerin
Heart rhythm medication
Dibetic
Digitalis
Diuretic
High blood pressure
Insulin
Other
None
Please list any orthopedic conditions. Include any injuries in the last 6 months:
*
Check any of these health symptoms that occur frequently (2 or more times per month that require medical attention.)
*
Cough up blood
Abdominal pain
Low back pain
Arm and/or shoulder pain
Chest pain
Swollen joints
Feeling faint
Breathlessness w/slight exertion
Dizziness
Palpitation or fast heart beat
Unusual fatigue with normal activity
Other
None
Medical History
Check any of the following for which you have been diagnosed or treated by a physician or health professional:
*
Alcoholism
Anemia, sickle-cell
Anemia (other)
Back strain
Bleeding trait
Stroke
Thyroid problem
Ulcer
Congenital defect
Diabetes
Emphysema
Hearing loss
Epilepsy
Eye problems
Gout
Cancer
Heart problems
Cirrhosis
Concussion
Hyperlipidemia
Obesity
Kidney problems
Mental Illness
Neck strain
Phlibitis
Stress
HIV
Rheumatoid arthritis
Hypoglycemia
High blood pressure
Osteoperosis
Other
None
Check any surgeries you may have had:
*
Back
Heart
Kidney
Eyes
Joints
Neck
Ears
Hernia
Lung
Gallbladder
Other
None
Check any paternal family member that died of a heart attack BEFORE age 55:
*
Grandfather
Father
Brother
Son
None
Check any maternal family member that died of a heart attack BEFORE age 65:
*
Grandmother
Mother
Sister
Daughter
None
Health Related Behaviors
Have you ever smoked?
*
Yes
No
How long ago and for how long?
*
Do you smoke now?
*
Yes
No
How many do you smoke per day:
*
1-9
10-19
20-29
30-39
40 or more
Do you currently exercise regularly?
*
Yes
No
Somewhat
Have you ever had a physical fitness test?
*
Yes
No
When?
*
How many days per week do you perform 30 minutes of moderate activity?
*
0
1
2
3
4
5
6
7
How many days per week do you perform at least 20 minutes of vigorous exercise?
*
0
1
2
3
4
5
6
7
What activities do you engage in at least 1X per week?
*
Walking
Cardio
Weights
Swimming
Chores
Gardening
Other
None
Current weight today:
*
Current weight 1 year ago:
*
Current weight at age 21:
*
Health Related Attitudes
Do you consider yourself as a hard-driving, time conscious, or impatient person?
*
Yes
No
Check any negative stress you experience:
*
Home
Family
Financial pressure
Social pressure
Personal health
Work
Self doubt
Other
None
What are your primary fitness goals?
*
What areas of your body do you want to improve the most?
*
What obsticles have stopped you in the past to accomplish your goals?
*
What is different this time?
*
When would you like to see results?
*
Nutrition
Do you have any food allergies?
*
Yes
No
Please list:
*
Do you suffer from (check all that apply)
*
Chrone's disease
Hasimotos
MS
Celiac
Hiatyl hernia
Diverticulitus
Other Autoimmune disorder
None
Are you on any weight loss program?
*
Yes
No
Please list:
*
How much weight would you like to lose?
*
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