Health & Lifestyle Evaluation Name * First Name Last Name Email * Age Phone (###) ### #### Height Weight Message Medical History Please check if applicable: Diabetes High Cholesterol Heart Murmur High Blood Pressure Chest Pains Stroke / Aneurysm Do you experience any of the following during exercise Check if yes Chest Pain Shortness of Breath Abnormally Tired Leg Pain Dizziness Fainting Difficulty Sleeping Other - Please write in notes below Have you had any other medical conditions / disorders (metabolic, pulmonary, cardiac) and/or gastric intestinal problems that we should be aware of? If Yes please explain below Have any of your first-degree relatives (parents or siblings) experienced the following conditions? (Check if Yes) In addition, please identify at what age the condition occurred. Please explain any checked items below High Blood Pressure Heart Attack Heart Operations Diabetes High Cholesterol Any other major illnesses If any checked yes, please explain Has your physician ever advised you against exercise? Yes No Are you currently pregnant? Yes No Are you currently taking any medications? Yes No If yes please list medications Do you currently smoke and/or have quit smoking in the previous 6 months? Yes No 1. Let us help you create some SMART goals (Specific Measurable Attainable Realistic & Timely) – What are some of your goals? 2. Is there a certain time frame you are trying to reach these goals in? 3. If a genie were to pop out of a bottle and grant you three perfect body parts what would they be? 4. What are some reasons you feel you haven’t reached them in the past? 5. Workout History: What type of workouts are you currently doing? 6. What are your favorite types of workouts? 7. IF YOU HAVE BEEN EXERCISING...How long have you been doing that type of workout? 8. How many days a week do you normally workout? 9. IF NO EXERCISE... Have you ever done a resistance training program before? If so, how did you feel at that time? 10. When is the last time you have had a personalized program for yourself? 11. On a scale from 1 – 10 (1 being the worst 10 being the best), how would you rate your eating habits? 12. Have you had a nutritional consultation or worked with a registered dietitian? 13. How do you sleep? On average, how many hours a night do you sleep? 14. What are your top three areas of stress? 15. What is your number one expectation from working with me? Please let us know if you have any concerns or special requests not covered above On a Scale of 10-10, how pumped are you to start your wellness journey at Island Movement? 10 11 LFG Thank you!
