INTAKE QUESTIONNAIRE


Today’s date:


Name:


Age:


Address:


Town:


State:


Zip:


Phone Number(s):


Email:


Gender:
MaleFemale

If female- any chance you are pregnant?
NoYes

Any history of spinal injury or injury to a joint or muscle?


Does it still affect you? Please describe:

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


Current Bodyweight(lbs.):

Current Body Fat Percentage(%):

Body Girths:


Waist(inches)

Hips(inches)

Legs

Left(inches)
Right(inches)

Upper Arm

Left(inches)
Right(inches)

Forearms

Left(inches)
Right(inches)
Shoulders(inches)
Chest(men only)(inches)

What are your current health/fitness goals?


What are the main reasons for your goals?

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):


Do you smoke?
NoYes

How much?
perDayWeekMonth


Did you quit smoking less than 6 months ago?
NoYes

Do you take antihypertensive medications?
NoYes

Are you currently taking Beta-blockers?
NoYes

Do you get at least 30 minutes of moderate physical activity everyday?
NoYes

Do you have osteoporosis?
NoYes

Do you have osteoarthritis?
NoYes

Do you suffer from back pain?
Yes(upper)Yes(mid)Yes(low)No

If yes, how often?
RarelyDailyWeeklyMonthly

Are you often stressed?
NoYes

If yes, how does it physically manifest?
HeadacheStomachSleeplessIrritableOther

How many times do you get sick (common cold) per year?
1234More

Do you have diabetes?
NoYes(type I)Yes(type II)

Are you taking any medications? List:


Do you eat low, moderate or high carbs?
LowMidHigh

Do you eat low, moderate or high protein?
LowMidHigh

Do you eat low, moderate or high fat?
LowMidHigh

Do you eat a variety of foods (whole grains, dairy, lean meats, fruit & vegetables with limited fat/oils)?
YesNo

How many calories do you eat per day?(Kcal)

What level of importance do you place on exercise?
NoneLowAverageModerateEssential

How often do you currently exercise?


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


How many days per week do you want to commit to exercise?
1234567

How many minutes per day?
20 or lessabout 304560an hour (+)

Rate your fitness (1-Poor, 5-Average, 10-Excellent):

Cardio-Respiratory
12345678910

Strength
12345678910

Endurance
12345678910

Flexibility
12345678910

Power
12345678910

Body Composition
12345678910

Self-Image
12345678910

Other Comments