Book your free consultationNew client? Talk to Marcus about your fitness goals and learn more about what he can offer you. Book Here New Client Consultation Name * First Name Last Name Email * Phone * (###) ### #### Preferred Method of Contact Phone Email Message * Thank you! Book your next sessionContact Marcus to setup your next training session or package. Book Here Book Your Next Session Name * First Name Last Name Email * Phone * (###) ### #### Message * Let us know what your fitness goals are, as well as dates and times which work best for you. Thank you! New client forms below. New Client Forms Physical Assessment Liability Waiver Health Assessment Lifestyle and Health History Name * First Name Last Name Date of Birth * MM DD YYYY How would you describe your present state of health? * Very Well Healthy Unhealthy Unwell List your current medications, how often you take them, and dosages (include prescriptions and over the counter medications). Do you take all of your medications as they have been prescribed by your healthcare provider? Yes No If you answered no above please share why (e.g., cost, side effects, or feeling as though they are unnecessary). Do you take any vitamin, mineral, or herbal supplements? Yes No If you answered yes above please list type and amount per day. When was the last time you visited your physician? Have you ever had your cholesterol checked? Yes No Date of test MM DD YYYY What were the results? Total cholesterol? High-density lipoprotein (HDL)? Have you ever had your blood sugar checked? Yes No What were the results? Please check any that apply to you: Alergies Amenorrhea Anemia Anxiety Arthritis Asthma Celiac disease Chronic sinus condition Constipation Crohn's disease Depression Diabetes Diarrhea Disordered eating Gastroesophageal reflux disease (GERD) High blood pressure Hypoclycemia Hypo/hyperthryroidism Insomnia Intestinal Problems Irritability Irritable bowel syndrome (IBS) Menopausal symptoms Osteoporosis Premenstrual syndrome (PMS) Polycystic ovary syndrome (PCOS) Pregnant Skin Problems Ulcer Describe your allergies, if any: List any major surgeries: List any past injuries: Describe any other health conditions that you have: Has anyone in your immediate family been diagnosed with the following? Heart disease High cholesterol High blood pressure Cancer Diabetes Osteoporosis If you answered yes to the above, what was the relation & their age when diagnosed? What are your dietary goals? * Have you ever followed a modified diet? Yes No If yes, describe: Are you currently following a specialized eating plan (e.g., low-sodium or low-fat)? Yes No If yes, describe: Why did you choose this eating plan? Was the eating plan prescribed by a physician? Yes No How long have you been on the eating plan? Have you ever met with a registered dietitian or attended diabetes education classes? Yes No If no, are you interested in doing so? Yes No What do you consider to be the major issues with your nutritional choices or eating plan (e.g., eating late at night, snacking on high fat foods, skipping meals, or lack of variety)? How many 8 ounce glasses of water do you drink per day? What do you drink other than water? List what and how much per day. Do you have any food allergies or intolerance? Yes No If yes, list your allergies: Who shops for and prepares your food? Self Spouse Parent Minimal preparation How often do you dine out each week? Please specify the type of restaurants for each meal: Breakfast, lunch, dinner, and snacks. Do you crave any foods? Yes No If yes, please specify: Do you drink alcohol? Yes No If yes how much and how often? Do you drink caffeinated beverages? Yes No If yes, average number of caffeinated beverages per day: Do you use tobacco? Yes No If yes, how much per day? Cigarettes, cigars, or chewing tobacco Do you currently participate in any structured physical activity? Yes No How many minutes of cardiorespiratory activity per week? How many minutes of muscular-training sessions per week? How many minutes of flexibility-training sessions per week? How many minutes of sports or recreational activities per week? List the sports or other activities you participate in: Do you engage in any other forms of regular physical activity? Yes No If yes, describe: Have you ever experienced any injuries that may limit your physical activity? Yes No If yes, describe: Do you have any physical activity restrictions? Yes No If yes, describe: What are your honest feelings about exercise/physical activity? What are some of your favorite physical activities? Do you work? Yes No If yes, what is your occupation? What is your work schedule? Describe your activity level during the day: How many hours of sleep do you get a night? Rate your average stress level from 1 (no stress) to 10 (constant stress): What is most stressful to you? How is your appetite affected by stress? Increased Not affected Decreased What is your present weight if known? What would you like to do with your weight? Lose weight Gain weight Maintain weight What was your lowest weight within the past 5 years? What was your highest weight within the past 5 years? What do you consider to be your ideal weight? What are your current waist and hip circumferences if known? What is your current body composition if known? % body fat On a scale of 1 to 10, how likely are you to adopt a healthier lifestyle? 1 = very unlikely, 10 = very likely. Do you have any specific goals for your health? Do you have a weight loss goal? If yes, why do you want to lose weight? Thank you! Exercise Preparation Exercise Prescreening Questionnaire Name * First Name Last Name Do you experience any of the following: * Chest discomfort with exertion Unreasonable breathlessness Burning or cramping sensations in your lower legs when walking short distances Dizziness, fainting, blackouts Ankle swelling Unpleasant awareness of a forceful, rapid, or irregular heart rate Have you performed planned, structured, physical activity for at least 30 minutes at a moderate intensity on at least 3 days per week for the past 3 months? * Yes No Do you have or have you had: * A heart attack Heart surgery, cardiac catheterization, or coronary angioplasty Pacemaker/implantable cardiac defibrillator/rhythm disturbance Heart valve disease Heart failure Heart transplantation Congenital heart disease Diabetes Renal disease Thank you!
