Name
*
Phone:
*
Email
*
Exercise
Number of months expected to attain goal
What exercise and/or recreational activities have you participated in during the past, are currently engaged in, or plan to engage in the future?
What would you like to see change on your body in one month?
What would you like to look like 1 year from now?
How many days are you committed to workout each week?
Have you ever worked out with a personal trainer?
If yes, were you pleased with the results and level of service? Please explain
Rate your level of Daily Stress
Rate your level of Daily Stress: 1 2 3 4 5
Diet
Do you use a water filter at home and work? If so what type/brand?
Do you drink alcohol?
Do you drink alcohol? Yes No
If so, how much?
What other beverages do you drink?
List any food allergies:
List any foods that you refuse to eat:
Are you taking any supplements?
Are you taking any supplements? Yes No
If so, which ones?
Do you have someone prepare meals for you?
Have you ever worked with a nutritionist?
Have you ever worked with a nutritionist? Yes No
If yes, were you pleased with the results and level of service? Please explain.
Have you ever been on a weight loss program before?
Have you ever been on a weight loss program before? Yes No
If yes, which one(s)?
What type of eating pattern have you been told you should follow?
When was your diet the most disciplined?
What type of eating pattern did you follow at that time?
What and when did you eat yesterday?
Do you smoke?
Do you smoke? Yes No
Have you ever done a detoxification diet/cleanse?
Have you ever done a detoxification diet/cleanse? Yes No
If so, how much?
If yes which one (s)?
Medical History
List any and all health conditions, medical problems and medications:
List non-prescription drug use: (i.e. Aspirin).
List any recent injuries and/or medical procedures:
Heart attack, coronary bypass or surgery
Heart attack, coronary bypass or surgery Yes No
High blood pressure
High blood pressure Yes No
Chest discomfort or pain during exertion
Chest discomfort or pain during exertion Yes No
Low blood pressure
Low blood pressure Yes No
Frequent Headaches
Frequent Headaches Yes No
Heart beat irregularities
Heart beat irregularities Yes No
Muscular skeletal diseases (i.e. MS, MD, AMS, or Cerebral Palsy)
Muscular skeletal diseases (i.e. MS, MD, AMS, or Cerebral Palsy) Yes No
Vascular disease
Vascular disease Yes No
Phlebitis, emboli
Phlebitis, emboli Yes No
Is there any reason not mentioned on the previous page why you should not follow a regular resistance-training program? If so what is the reason? is invalid
For any of the conditions checked above, please list the diagnosis and examining physician.
Shortness of breath, especially during mild exertion
Shortness of breath, especially during mild exertion Yes No
Examining Physician:
Phone number:
Light headedness or fainting spells
Light headedness or fainting spells Yes No
When was your last comprehensive physical examination?
Primary Physician:
Phone number:
Cardiorespiratory disease (i.e. asthma, bronchitis)
Cardiorespiratory disease (i.e. asthma, bronchitis) Yes No
High or Low cholesterol or triglyceride levels
High or Low cholesterol or triglyceride levels Yes No
Stroke
Stroke Yes No
Past orthopedic injuries
Past orthopedic injuries Yes No
Recent illness (serious), hospitalization or surgery within past 6 months
Recent illness (serious), hospitalization or surgery within past 6 months Yes No
If yes, to what degree has the injury been rehabilitated?
Diabetes or other metabolic disorders
Diabetes or other metabolic disorders Yes No
Gout
Gout Yes No
Current pregnancy
Current pregnancy Yes No
Is there a history of cancer in your family?
Is there a history of cancer in your family? Yes No
Has your doctor ever told you that you have a bone, joint or any other orthopedic problem that has been or could be made worse by resistance training?
Has your doctor ever told you that you have a bone, joint or any other orthopedic problem that has been or could be made worse by resistance training? Yes No
Would your physician object to your dieting or exercising?
Would your physician object to your dieting or exercising? Yes No
Symptoms
Average sleep time in hours (weekdays)
Average sleep time in hours (weekends)
Do you find it difficult falling asleep or waking up in the morning?
Do you find it difficult falling asleep or waking up in the morning? Yes No
Bowel Health
Holistic Care
Do you currently see a chiropractor?
Do you currently see a chiropractor? Yes No
If yes, are you pleased with the results and level of service? Please explain.
Do you currently see an acupuncturist?
Do you currently see an acupuncturist? Yes No
If yes, are you pleased with the results and level of service? Please explain.
Have you ever used a Far-Infrared Sauna?
Have you ever used a Far-Infrared Sauna? Yes No
If yes, please explain.
Have you ever seen a Colonic Therapist?
Have you ever seen a Colonic Therapist? Yes No
If yes, please explain.
Have you used other Holistic Modalities?
Have you used other Holistic Modalities? Yes No
If yes, please explain.
If you are human, leave this field blank.
