Fitness Essentials

Download the PDF Version of the Intake Form

Health/Fitness History (Confidential Information)


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Referred By
Date
Name (Last, First, MI)
PAA Member Number
Fitness Number
Address (Street, City, ST, Zip)
Email
Home Phone
Work Phone
Occupation
Age
Date of Birth
Sex
Height
Weight
Drug Allergies



Physician Information

Physician's Name
Type of Physician
Business Address (Street, City, ST, Zip)
Phone
Has your physician referred you to an exercise program? Yes No
Have you ever had a Stress Test? Yes No
If yes, how long ago?
For what reason was this test performed?
Has your physician cleared you for exercise? Yes No
No Physician Comment
Would you like progress reports sent to your physician? Yes No



Personal Health History (Please check the appropriate column, if applicable)
  Personal Family   Personal Family
Allergies Hypertension
Anemia Hypotension
Asthma Hepatitis
Arthritis Heart Condition
Bronchitis (Specify)
Bursitis Kidney Disease
Cancer Mononucleosis
(Specify type/location) Osteoporosis
Cirrhosis Pneumonia
Claudication Respiratory Condition
Chronic Cough Rheumatic Fever
Diabetes Severe Headache
Dizziness/Fainting Stroke
Emphysema Other (Specify)



Medications

Are you currently taking any medications? Yes No
If yes, please list medication:



Orthopedic and Other Health Concerns

Have you ever had muscle, bone or joint illness or injury (including the back) in the past? Yes No
If yes, please explain:
Do you currently have any muscle, bone or joint problems that may affect your activity level? Yes No
Please explain any other health concerns or complications
Has a physician ever placed any restrictions on your activities? Yes No
If yes, please explain:



General Health Status

Do you have a history of high cholesterol? Yes No
Do you know your value? Yes No
Has your body weight changed more than 10 pounds in the last year? Yes No
How would you evaluate your health status over the past 6 months? Same Better Somewhat Worse Significantly Worse
Do you presently feel that you are in good health? Yes No
How many hours of sleep do you get a night?
Other comments



Personal Habits

Do you smoke at present? Yes No
Have you ever smoked? Yes No
If yes, when did you quit?
Years smoked?
If currently smoking, would you like to quit? Yes No



Nutrition (For nutritional consultation, please fill out the Diet/Nutrition History attached to the end of this form)


Exercise

Do you currently engage in any form of regular exercise? Yes No
If yes, please specify:
Have you ever participated in a regular exercise program? Yes No
If yes, please specify:
Have you ever participated in competitive athletics? Yes No
If yes, please specify:
How much physical exertion is required in your occupation? Please specify:
What is your primary reason for starting an exercise program?
Please list at least three goals you wish to achieve through your personal fitness program, in order of importance:
What types of activities do you enjoy?
Are there any activities that you would like to try that you have never done before?
Are there any activities in which you do not want to participate?
Are there any other comments or concerns we need to know prior to your starting a personal fitness program?



Diet/Nutrition History (Confidential Information)
What do you consider a good weight for yourself? What is the most you have ever weighed?
Number of meals you eat per day? Number of meals you eat at home per day?
How many times a day do you eat (including snacks)?
Do you do the cooking at home? Yes No
Do you drink alcoholic beverages? Yes No
Do you use salt? Yes No
Do you drink coffee, tea or colas? Yes No
How many cups/glasses per day?
Do you take vitamins? Yes No
If yes, please list:
Do you take any supplements? Yes No
If yes, please list:
Are you on a special diet now? Yes No
If yes, please explain:
Approximately how many 8 oz. glasses of water do you drink per day?
Would you consider the portion size of your meals to be: Small Medium Large
What kind of snacks do you choose?
Approximately how many servings of fruit do you eat per day?
Approximately how many servings of vegetables do you eat per day?
Do you read food labels? Yes No
Do you consider your meals to be balanced? Yes No
How many meals a day do you eat sitting down at a table?
How many meals a day do you eat on the run?
Do you watch TV, read or listen to music when you eat?
Do you use artificial sweetners? Yes No
Do you eat breakfast? Yes No


Fitness Essentials, LLC
7101 Penn Ave., Pittsburgh
PA, 15208
Map


Contact Us
(p) 412.519.8471
(e) bfitness2@gmail


Our Training Locations
Fitness Essentials at Engine House 16 Collaborative
The Pittsburgh Golf Club - Personal Training
In-Home - Personal Training

 
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