Contact and Health Assessment Form

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
Use this to send any documents you want to share with me

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