Intake Questionnaire

1. Your information: *
2. Are you presently involved in a regular exercise program? *
3. If yes, please list activity, duration and frequency (example: power walk for 30 minutes, 4 times per week)
4. How active do you consider yourself? *
5. Please describe your knowledge of exercise and fitness. *
Heart Attack, Heart Disease, Diabetes (Type I, Type II), Foot Problems, High Blood Pressure, Low Blood Pressure, Neck Problems, Irregular Heart Beat, Swollen, Stiff, or Painful Joints, Anemia, Migraine/Recurrent Headaches, Shoulder Problems, Bronchitis, Back Problems, Epilepsy or Seizures, Shortness of Breath, Broken Bones, Emphysema, Limited Range of Motion in Joints, Dizziness or Fainting, Fatigue or Lack of Energy, High Cholesterol, Asthma, Hernia, Trouble Sleeping, Arthritis, Bursitis, Chest Discomfort, Osteoporosis/Osteopenia, Joint Replacement, or other (explain below).
6. If you currently have or had any of the above conditions in the past five years, please write them below. Or write "None" if none apply. *
7. Please list any prescription or over-the-counter medications (and dosage) you are now taking:
8. Please list any dietary supplements you are now taking:
9. Please check specific health and fitness goals that you want to achieve:
10. Additional Goals:
11. Do you have any injuries (past or present)? If yes, please explain.
12. Are there any specific types of training that interests you most? (i.e. Olympic style/Power lifting, strength training, calisthenics/body weight, boxing, yoga, Pilates).
13. Do you play any sports or are an active runner/cyclist/rower/skier, etc.? Please explain.
14. Which would best describe your daily activity level? *
15. How long has it been since you were consistently active? *
16. What is the level of activity at your job? *