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Client information & medical record
First Name
Last Name
Email
Age
Birthday
Phone number
How will you attend?
Physically
Online
Is this your first time attending?
Yes
No
Height?
Weight? (kg)
Has your doctor ever said you should consult them before undertaking activity?
Yes
No
Details?
Do you feel pain in your chest during physical activity?
Yes
No
Details?
Do you have high blood pressure?
Yes
No
Do you lose balancee, feel light headed or have dizzy spells?
Yes
No
Details?
Have you been in hospital in the last 12 months?
Yes
No
Details?
Has your doctor ever said you have heart trouble?
Yes
No
Are you currently taking medicine?
Yes
No
Details?
Do you suffer from arthritis that is aggravated by exercise?
Yes
No
Details?
Are you pre or post natal?
Yes
No
Months?
Do you suffer from asthma or breathing difficulties?
Yes
No
Details?
Do you suffer from diabetes?
Yes
No
Do you suffer from epilepsy?
Yes
No
Are you healthy enough to train at Body Evolution Fitness
Yes
No
If you answered YES to any of the above questions, please provide a doctors note before training. Check box to aknowledge.
Please note; If your health changes in any way during your new fitness regime or physical activity, please consult your fitness professional and seek advice from your doctor immediately. Check box to aknowledge.
Are you experiencing any stress at the moment? Any mood swings, relationship or work issues for which you would like to recieve some help or resources?
Yes
No
has anyone in your family developed heart disease prior to 60 years old?
Yes
No
Are you taking or recently used any prerscription or over the counter medications?
Yes
No
Symptoms/Conditions?
Loss of hearing
Asthma
Kidney disease
Prostalitis
Colitis
Hepatitis
Liver disease
heart attack
heart murmur
Sleep apnea
Angina
Heart failure
High cholesterol
High blood pressure
Arthritis
Loss of consciousness
convulsions/seizures
Stroke
Diabetes
Anemia
Cancer
*None of the above*
Please give the details and dosages below.
Have you had any surgical operations in the past 10 years?
Yes
No
Details?
Are you currently under doctors care? If so, please give details below.
Yes
No
Please give more details.
Have you any concerns that you would like to discuss with me or a doctor?
Yes
No
Please give more details.
Do you currently smoke?
Yes
No
How many and how long have you smoked?
Do you drink alcohol?
Yes
No
How many units per week?
Personal Goals
Tell me in number order what are your 3 main goals and the timescale that you would like to achieve them in?
Add most important goal here:
Timescale?
Add second most important goal here:
Timescale?
Add third most important goal here:
Timescale?
Past Exercise History
Are you currently exercising / training? If no skip this section
Yes
No
How long have you been training / exercising?
1-3 months
3-6 months
6-12 months
longer
How many times per week do you train?
1-3 days
3-5 days
6-7 days
Which types of exercising / training do you do?
Resistance (lifting weights)
Cardio (running, cycling, swimming etc
Sport
Rehab
In the box below, please let me know your weekly schedule for exercising or training.
Lifestyle
What is your job?
Do you work night shifts?
Yes
No
Do you work from home?
Yes
No
What are your daily stress levels?
Low (rarely stressed at home or work)
Moderate (occasionally have to deal with stressfull situations, but handle them well)
High (often dealing with stressfull situations that do have an effect on me)
Very high (constantly stressed at home and work, probably effect my life and health)
How many average daily walking steps do you do or think you do per day?
0-3000
3000-5000
5000-7500
7500-10,000
10,000-12,500
12,500-15,000
15,000 +
Don't know?
What are your biggest stresses?
How many average hours do you sleep every night?
4 hours or less
4 hours
5 hours
6 hours
7 hours
8 hours
9+ hours
Don't know?
Do you get bloated or gassy?
Yes
No
Do you know which foods make you bloat or gassy??
Can you tell me your daily routine. What time you get up, what time you eat your meals, what time do you go to work, pick up kids, go to the gym etc
Miscellaneous
Is there any informationyou would like to include that you feel may be important?
Social support
Do the people who spend time with each day follow a healthy lifestyle by exercising or eating healthy foods?
Yes, most of them do (+3)
At least half of them do (0)
