INTAKE QUESTIONNAIRE

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Today’s date:

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Name:

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Age:

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Address:

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Town:

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State:

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Zip:

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Phone Number(s):

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Email:

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Gender:
MaleFemale
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If female- any chance you are pregnant?
NoYes
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Any history of spinal injury or injury to a joint or muscle?

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Does it still affect you? Please describe:

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The following section will be completed by the trainer at the initial consultation:

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Current Bodyweight(lbs.):
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Current Body Fat Percentage(%):
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Body Girths:

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Waist(inches)
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Hips(inches)
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Legs

[one_half]Left(inches)[/one_half][one_half_last]Right(inches)[/one_half_last]

Upper Arm

[one_half]Left(inches)[/one_half][one_half_last]Right(inches)[/one_half_last]

Forearms

[one_half]Left(inches)[/one_half][one_half_last]Right(inches)[/one_half_last]

[one_half]Shoulders(inches) [/one_half]

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What are your current health/fitness goals?

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What are the main reasons for your goals?

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Check any symptoms of possible coronary or metabolic disease you have recently experienced:

Chest painshortness of breathdizzy/faintingankle swellingheart palpitationsleg/feet crampingheart murmur

Risk factors for CHD (Coronary Heart Disease), MI (heart attack), Stroke or hypertension (usually caused by atherosclerosis):

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Do you smoke?
NoYes
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[one_half]How much? [/one_half] [one_half_last]perDayWeekMonth[/one_half_last]
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Did you quit smoking less than 6 months ago?
NoYes
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Do you take antihypertensive medications?
NoYes
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Are you currently taking Beta-blockers?
NoYes
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Do you get at least 30 minutes of moderate physical activity everyday?
NoYes
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Do you have osteoporosis?
NoYes
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Do you have osteoarthritis?
NoYes
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Do you suffer from back pain?
Yes(upper)Yes(mid)Yes(low)No
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If yes, how often?
RarelyDailyWeeklyMonthly
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Are you often stressed?
NoYes
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If yes, how does it physically manifest?
HeadacheStomachSleeplessIrritableOther
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How many times do you get sick (common cold) per year?
1234More
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Do you have diabetes?
NoYes(type I)Yes(type II)
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Are you taking any medications? List:

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Do you eat low, moderate or high carbs?
LowMidHigh
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Do you eat low, moderate or high protein?
LowMidHigh
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Do you eat low, moderate or high fat?
LowMidHigh
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Do you eat a variety of foods (whole grains, dairy, lean meats, fruit & vegetables with limited fat/oils)?
YesNo
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How many calories do you eat per day?(Kcal)
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What level of importance do you place on exercise?
NoneLowAverageModerateEssential
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How often do you currently exercise?

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What type(s) of exercise do you usually perform?

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How many days per week do you want to commit to exercise?
1234567
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How many minutes per day?
20 or lessabout 304560an hour (+)
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Rate your fitness (1-Poor, 5-Average, 10-Excellent):

Cardio-Respiratory
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Strength
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Endurance
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Flexibility
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Power
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Body Composition
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Self-Image
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