Lifestyle/ Equipment Inventory Intake Form
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1 Lifestyle/ Equipment Inventory Intake Form General Information Name: Referred by: Address: Date: How did you hear about us? Home Phone #: Cell #: Occupation: Age: Physician Information Physician Name: Address: Date of Birth: Gender: Contact #: Has your physician referred you to an exercise program? Has your physician cleared you for exercise? Are you taking any medication? Have you ever had muscle, bone, or joint illness or injury (including the back) if yes, please explain: Do you currently have any muscle, bone or joint problems that may affect your activity level? Has a physician ever placed any restrictions on your activities? Equipment Access Please list the equipment you will be using if not using a Box Gym
2 Body Type and Composition (Body fat and Muscle % are optional if you have this information) Weight (lbs): Height (feet): Body Fat %: Muscle %: Measurements Chest: Waist: Hips: Left Thigh: Right Thigh: Left Arm: Right Arm: Left Calf: Right Calf: Neck: Wrist: Waist/Hip Ratio: Body Type (Place an X on the pink line above the body type that mostly resembles your body type) ECTOMORPH MESOMORPH ENDOMORPH Narrow hips and clavicles Small joints (wrist/ankles) Thin build Stringy muscle bellies Long limbs Wide clavicles Narrow waist Thinner joints Long and round muscle bellies Blocky Thick rib cage Wide/thicker joints Hips as wide (or wider) than clavicles Shorter limbs Goals 1. What is your goal? (Fat loss, Toning, Muscle Mass, Maintenance, Health) 2. What goal do you want to achieve in 12 months? (Weight, fat %, Muscle %) 3. How do you have in your circle that can help you achieve these goals?
3 4. What special service do you need assistance with achieving this goals? 5. What personal areas do you need to work on to achieve these goals? 6. Break down your goal in quarters and write down what your goal is; 1 st Quarter 2 nd Quarter 3 rd Quarter 7. Will you be attending a gym or your home gym for fitness activity? Lifestyle Interview 1. Have you worked with a personal trainer in the past? 2. What exercise have you participated in the past or now?(please list) 3. How many hours on average do you sleep daily? (Include naps) 4. Do you currently smoke? 5. Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking and the amounts/dosages and brands: 6. Do you have any allergies or sensitives to food or environment? If so, please list: Health interview 1. How often do you have a bowel movement? 2. Do you experience constipation? 3. Do you have loose bowel movements? 4. Do you see leafy vegetable or fat in your stool?
4 Dietary Questionnaires 1. How many times do you eat per day (including snacks) 2. Do you eat every 3 hours? 3. Do you prefer to have 3 large meals per day or 3 small with snacks in-between? 4. Where do you eat the majority of your meals (home, on the run, restaurants/fast food)? 5. Do you cook most of your meals? 6. Do you enjoy eating leafy greens? 7. What types of foods do you crave? 8. Are you an emotional eater? 9. Are you a binge eater? 10. How much water do you drink daily? 11. How much coffee do you drink daily? 12. How much pop/juice do you drink daily? 13. How much Alcohol do you drink weekly? 14. What is your preference (Vegetarian, Vegan, Meat eater, No preference)? 15. List the foods you avoid to eat? 16. List the foods you love to eat and wish for them to be part of a healthy lifestyle? 17. Please give examples of your typical meals you consume daily Breakfast: Lunch: Dinner: Snacks: Beverages:
5 Tailored Fitness Program Goals & Equipment Inventory Goals Please check off any of the following goals you are trying to achieve in your Tailored Fitness Program FAT LOSS MUSCLE GAIN FAT LOSS & MUSCLE GAIN TONING SLENDER LOOK JOINT CORRECTION FITNESS PRE SURGERY FITNESS POST SURGERY FITNESS BALANCE POSTURE PELVIC FLOOR CORRECTION AB SEPERATION CORRECTION PRE PREGNACY FITNESS DURING PREGNANCY FITNESS POST PREGNACY FITNESS SPORTS RELATED FITNESS SPARTAN TRAINING LONG DISTANCE /SHORT DISTANCE RUNING TRAINING MAITIANCE FITNESSS ACTIVE AGING FITNESS (60+ YRS) METABOLIC FITNESS (hyperthyroid, menopause, post menopause, perimenopause) STRESS REDUCTION FITNESS What is your 12 month, 6 months and 3 month goals? Please indicate more information about your goals here: How many day s a week can you dedicate to your fitness program? What duration/time can you dedicate your fitness per session? What time of the day can you complete your fitness program?
6 Equipment Inventory Please list of the equipment you have that will be included into your tailored fitness program, also attach picture to the if you are unsure of the name of your equipment. Please be specific type, how many, LBS
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Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age
Health Profile ALTH PROFILE Dietary consultation involves a health profile which purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight-loss
Pediatric Questionnaire
1 Pediatric Questionnaire Child s Name: First Last Middle Initial Parent(s) Name(s): Address: Street City State Zip Phone: Work: Cell : EMAIL: Fax: Child s birth date: Child s Sex (Circle One): Male/Female