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Client Personal Information

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Name

Age

Gender

Height

Weight

Physican Name and Phone #

Emergency Contact Name and Phone #

EXERCISE

What exercise activities do you currently take part in (e.g., running, weightlifting, group exercise, etc.)?

How many days per week do you get at least 60 minutes of moderate-intensity exercise?

 

On a scale of 0 to 10, how important are the following fitness goals to you?

Weight loss:

0 1 2 3 4 5 6 7 8 9 10

Muscle gain:

0 1 2 3 4 5 6 7 8 9 10

Sports performance:

0 1 2 3 4 5 6 7 8 9 10

Health improvement:

0 1 2 3 4 5 6 7 8 9 10

Are you currently following any kind of diet? If so, what diet and for what reason(s)?

How would you rank your daily salt intake: low, medium, or high?

How would you rank your daily fat intake: low, medium, or high?

Do you consume caffeinated beverages such as coffee, tea, soda, and/or energy drinks? How many per week?

LIFESTYLE

Do you feel like you get enough sleep and wake up feeling rested each day?

On a scale of 0 to 10, how would you rate your average level of stress?

0 1 2 3 4 5 6 7 8 9 10

What techniques do you currently use to manage your stress levels?

Do you smoke tobacco or use a vaporizer alternative?

OCCUPATION

What is your occupation?

Does your occupation require extended periods of sitting? (If YES, please explain.)

Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots)?

RECREATION

Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.)

Do you have any additional hobbies (gardening, fishing, music, etc.)? (If YES, please explain.)

MEDICAL

Please list out any past musculoskeletal injuries:

Please list out any past surgeries:

If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity?

Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonary disorders, hypertension, diabetes, or cancer)? (If YES, please explain.)

Are you on any medications, and if so, have you received clearance from your doctor to take part in physical activity?

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