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Client Health & Lifestyle Assessment
How did you hear about us? *      
Name *      
Birthday (mm/dd/yyyy) *
Height:  *      
Weight: *      
Sex:  Male Female *      
         
Contact Information
         
Address *      
City *      
State *      
Zip *      
Home Phone      
Work Phone      
Cell Phone      
         
Best Number to Reach you:    Home Work Cell phone      
Best Time to Contact you:     Morning Afternoon Evening      
         
Email *      
Spouse/Significant other      
Children (names & ages)      
         
Person to Contact in case of emergency:       
Name:       
Phone:       
         
Health Care Services
         
Physician’s Name:      
Physician’s Phone:       
Indicate the date of each exam if know, otherwise check the appropriate timeframe
Date
Within the last year
Within the last 2—3 years
More than 4 years ago
Last Physical Exam
Last Eye Exam
Last Dental Exam
Last Foot Exam (if diabetic)
         
Yes No Have you been to the emergency room in the past 12 months?
(If yes, please explain. Number of times, reason for visit, etc.)
   
Yes No Have you been hospitalized in the past 12 months?
If yes, please explain (Number of times, reason for hospitalization, etc.):
   
   
   
Past and Present Personal Health History
Check All That Apply:        
Diseases of the heart and arteries
Abnormal electrocardiogram (ECG)
High Blood Pressure
High Cholesterol
Angina Pectoris (Chest Pain)
Epilepsy
Stroke
Anemia
Abnormal Chest X-Ray
Cancer
Asthma
Other Lung Diseases:
Orthopedic or Muscular Problems
Hernia (now or in the past)
Diabetes:  type 1 type 2 other
Year Diagnosed:
Pregnancy (now or within last 3 months)
Recent Surgery (within the last 12 months)
Chronic illness or condition
Other medical condition not mentioned
   
If any of the above are checked, please explain further and indicate any recommendations your doctor has made regarding exercise:
 
   
Yes No

Are you currently taking medication prescribed by a physician? 
(If yes, please indicate name of medication, dosage and reason for taking it):
         
Risk Factors
         
Is there a family history of:
heart disease hypertension
stroke diabetes
heart failure lung disease
epilepsy obesity
If yes, please indicate who the relative is, the medical problem, and the age of onset or death:
Yes No Have you in the past or do you currently smoke cigarettes?
  1. How many years have you/did you smoke?
  2. How many cigarettes do you smoke per day? 
  3. When did you quit?
   
Yes No Do you consume alcohol on a regular basis?
  1. On average, how many drinks do you consume per week:
1-5 5-10 More than 10
  2. Type of alcohol consumed
Are there any other risk factors that we should know about?
         
Physical Activity
         
In the past year, how often have you been engaged in physical activity?
Regularly (3 to 4 times/week)
Semi-regularly (1 to 2 time/week)
Sporadic (1 to 2 times/month)
None
 
Yes No

Are you currently involved in a regular aerobic exercise program  (walking, cycling, swimming, step aerobics, etc)?
  1. minutes/day? days/week
  2. type(s) of activity: 
   
Yes No Are you currently involved in a strength-training program?
  1. minutes/day? days/week
  2. Muscle groups trained
Yes No

Do you perform stretching exercises on a regular basis? (Everyday or at least after every workout)
Rate yourself on a scale of 1 to 5 (1 lowest – 5 highest)
Your present athletic ability 1 2 3 4 5
Your present cardiovascular capacity 1 2 3 4 5
Your present muscular capacity 1 2 3 4 5
Your present flexibility capacity 1 2 3 4 5
         
What are your personal barriers to exercise (i.e., your reasons for not exercising)?
         
What physical activity have you been successful with in the past (liked and participated in regularly)?
         
Do you have any physical problems that limit exercise? Please explain.
         
Training Preferences
         
Below is a list of activities that you can participate in without having to belong to a gym.  Please select any that are of interest to you and rank your top three.  This information will be used to design your personalized Cardiovascular Training Program.
Rank your Top 3
Walking
Running
Biking
Hiking/Stair Climbing
Roller-blading
Swimming
Stationary Equipment (i.e. Treadmill)
Video Workouts (i.e Tae-bo, Jazzercise)
Other:
     
What areas of your body would you like to focus on improving?
 
Nutrition
         
Who prepares meals in your home?      
Do you eat meals as a family?   Yes No      
How many in household?      
What meals do you eat together? Breakfast Lunch Dinner      

How many meals per week do you eat away from home?

 None 1-3 4-7 8 or more
What are your favorite foods?      
What foods do you dislike?      
What types of beverages do you usually consume?       

Do you have any special diet or eating habits that we should know about (allergies, intolerances, religious or cultural considerations, etc.)?
         
What time do you typically eat breakfast?      
    What do you eat?      
What time do you typically eat lunch?      
    What do you eat?      
What time do you typically eat dinner?      
   What do you eat?      
         
Yes No Do you snack during the day?

     
  1. When do you typically snack?
  2. What do you eat?
     
         
What do you feel are your biggest nutritional challenges? (Check all that apply and rank your top 3):
Skipping meals
Overeating
Dining out
Sweets
Snacking
Unbalanced diet
Others:
     
 
         
What types of diets have you tried in the past?
         
Which diet(s) did you lose the most weight on?
         
Which diet(s) were the easiest to follow?
         
Would you prefer to be given:
A meal plan to follow OR a daily caloric intake range
         
Occupation/Leisure
         
What is your present Occupation?      
         
How many hours per week do you work?      
         
Yes No

Does your occupation require much activity? (walking, getting up and down, carrying things)? |
Please Describe:

         
What are your typical leisure activities?      
         
What is your favorite kind of music/artist?      
         
Stressors/Sleep Habits
         
What is your typical daily stress level?  1-10 (10 being highest)       
         
What things make you feel stressed?      
         
How do you typically deal with stress?      
         
How many hours of sleep do you typically get per night?      
         
What time do you usually go to bed?      
         
What time do you usually wake up?      
         
Goals/Expectations
         
What is your motivation to begin this program? (Check all that apply and rank your top 3):
Lose weight/inches
Improve muscle strength
Improve muscle endurance
Improve cardiovascular endurance
Improve flexibility
Sculpt/tone body
Improve eating habits
Others:
         

Where do you need the most support from RESULTS? (Check all that apply and rank your top 3):

Accountability/Motivation
New ideas/Creative programming
Safety
Fitness/Nutrition education
Others:
         
What do you like best about your body?      
         
What do you like least about your body?      
         
Do you have a specific cardiovascular goal (run a 5k, learn to swim, etc)?      
         
Specifically describe what you would like to accomplish through your fitness program during the next:
   12-weeks
  6-months
  1-year
         
What else would you like us to know about your goals and expectations?
         
Services & Scheduling
Please indicate what services you’re interested in:
Nutrition Services: Dietetic Evaluation & Recommendations
Nutrition Services: Shop Smart Grocery Consultation
Weight Management Program
Fitness Coaching
Specialty Training
    Rehabilitative: Please give us some details (type of injury, rehabilitation history, etc):
Sport Specific: What sport(s)
Fitness Boot Camp
Youth Fitness Camp
Personal Training
         

If you’ve chosen to Personal Train with Results, please indicate how often you’d like to work with a trainer, and what days and times would be most convenient for you:

Sessions per week:
 1 2 3 4 5
Location:
 Home or Office
Day(s):
 Mon Tue Wed Thur Fri Sat
Time(s):
Morning
Afternoon
Evening

         
Diabetes History
         
When were you diagnosed?      
         
What kind of diabetes education have you had?      
         
How do you keep up to date with diabetes information?      
         

What brand of insulin do you use?

 Lilly Novo Aventis Other
         
How is your insulin measured?      
         
How is your insulin administered?      
         
What injection site(s) are used?        
Abdomen Thigh Arm Buttock Other:
         
Yes No

Do you change your diabetes medication (dosage, frequency, etc.) without direction from your physician?
         
What type of glucose monitor do you use?      
         
How many times per day do you test?      
         
Test times:      
         
Is there anything else we should know regarding your condition?      
         

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