Client Information Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has a doctor ever said you have a heart condition & that you should only do physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you do physical activity? *

Yes

No

In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

Do you lose your balance because of dizziness, or do you ever lose consciousness? *

Yes

No

Do you have a bone or going problem (fore example, back, knee or hip) that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes

No

Do you know of any other reason why you should not do physical activity? *

Yes

No

Medical History. Select all that apply. *

Heart Disease or Stroke

High Blood Pressure

Cancer

Lung/Pulmonary Disease

Kidney/Liver Disease

Ulcer (Stomach)

Gastrointestinal Disease

Depression

Arthritis

Food Allergies confirmed by a physician

Neuromuscular Disease

Arteriosclerosis

Gallbladder Disease

Pregnant

Date *

MM

DD

YYYY