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Consulting form
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Consulting form
Personal Information
Medical History
History of a heart problem (ie chest pain, heart murmrur or stroke)
Diabetes
Asthma, breathing or lung problems
Allergies
Cancer
Seizures, neurological problems, dizziness
High blood pressure
Back problems, joint or muscle disorder still affecting you
Recent surgery
Hernia or any condition that may be aggravated by exercise)
Physician's advice not to exercise
History of high cholesterol
Do you smoke
Do you consume alcohol
Do you take supplements of any kind
Are you on any medication
Do you have joint problems that might be aggravated by exercise
Is stress from daily living an issue in your life
Skeletal Injuries
Goals
On a scale of 1-10 please indicate how important it is for you to achieve this goal?
1
2
3
4
5
6
7
8
9
10
Nutrition
How many times a day do you eat?
1
2
3
4
5
6+
How many Litres of water do you consume per day?
Describe a typical day of the food you would consume:
Exercise
How many times a week do you currently exercise?
