Contact and Health Assessment Form
Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Phone Number
*
-
Area Code
Phone Number
Cell Number
*
-
Area Code
Phone Number
Text Messaging?
*
Yes
No
Email
*
example@example.com
Best times to contact you?
*
Goals (Choose all that apply)
Nutrition
Strength
Flexibility
Injury Rehab
Balance
Agility
Muscle Tightness/Stiffness
Cardio
Do you drink water often?
*
Yes
No
If Yes, How many glasses per day?
*
1-3
4-7
8 or more
How many meals do you eat per day?
*
How many snacks per day?
*
List 5 foods or drinks that you feel like you "have to have" daily.
List of foods that you do not like.
Are you currently exercising?
*
Yes
No
What days could you commit to exercising?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please explain in detail and how often your current exercise schedule
*
*Ex. Walking, yoga, group exercise classes, weights, running
Injuries to any of the following areas?
*
Neck
Back
Low Back
Hip
Shoulder
Elbow
Wrist
Hands
Knee
Ankle
Foot
None
If Yes, Please Explain in detail
Do you have any of the following conditions? (Select All That Apply)
*
Diabetes
Heart Condition
High Blood Pressure
Low Blood Pressure
Fibromyalgia
Parkinsons
Epilepsy
Asthma
COPD
Multiple Sclerosis
Arthritis
None
Are you taking any medications?
*
Yes
No
If Yes, Please Explain
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