Exercise Intake Form
Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of phone
*
Email
*
example@example.com
Who are you seeing at Wellness?
Kara Griffith
Shannon McCluskey
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Primary Care Physician
*
Occupation
Hours per week working
Recreational activities & hobbies
Do you sit for long periods of time?
*
Yes
No
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Describe current structured exercise
Short term wellness goals
Long term wellness goals
Do you have any communication barriers
*
Yes
No
If yes, please explain
Do you have any known restrictions recommended to you by a physician or therapist
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Allergies (if yes please explain)
*
No
Yes
Anxiety (if yes please explain)
*
No
Yes
Arthritis (if yes please explain)
*
No
Yes
Blood Clots (if yes please explain)
*
No
Yes
Blood irregularities (if yes please explain)
*
No
Yes
Bone or Joint problems (if yes please explain)
*
No
Yes
Cancer (if yes please explain)
*
No
Yes
Congestive heart failure (if yes please explain)
*
No
Yes
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Coronary artery disease (if yes please explain)
*
No
Yes
Depression (if yes please explain)
*
No
Yes
Diabetes (if yes please explain)
*
No
Yes
Eating disorders (if yes please explain)
*
No
Yes
Endocrine disease (if yes please explain)
*
No
Yes
Epilepsy (if yes please explain)
*
No
Yes
Heart attack (if yes please explain)
*
No
Yes
High blood pressure (if yes please explain)
*
No
Yes
High cholesterol (if yes please explain)
*
No
Yes
Irregular heart beat (if yes please explain)
*
No
Yes
Kidney disease (if yes please explain)
*
No
Yes
Lung disease (if yes please explain)
*
No
Yes
Muscular issues (if yes please explain)
*
No
Yes
Osteoporosis (if yes please explain)
*
No
Yes
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Pacemaker or implants (if yes please explain)
*
No
Yes
Peripheral arterial disease (if yes please explain)
*
No
Yes
Poor balance or falls (if yes please explain)
*
No
Yes
Pregnancy (if yes please explain)
*
No
Yes
Sleeping disorders (if yes please explain)
*
No
Yes
Spine conditions (if yes please explain)
*
No
Yes
Stroke (if yes please explain)
*
No
Yes
Surgeries (if yes please explain)
*
No
Yes
Thyroid condition (if yes please explain)
*
No
Yes
Any other conditions
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Please list all supplements, prescribed or over-the-counter medications, as well as the reason
How much sleep do you get
Do you feel rested in the morning (if no, please explain)
*
Yes
No
Rate your current stress level
*
Very low
Low
Moderate
High
Very high
Tobacco use (if yes, please list frequency/amount and type
*
No
Yes
Alcohol use (if yes, please list frequency/amount and type
*
No
Yes
Recreational drug use (if yes, please list frequency/amount and type
*
No
Yes
Including snacks, how many times do you eat per day
How long do you wait to eat after waking up in the morning
Do you skip meals
*
Yes
No
How many times per week do you eat out
Do you do your own shopping/cooking
*
Yes
No
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Servings of fruit per day
Servings of vegetables per day
Do you ever eat because of boredom, stress, ect
*
Yes
No
If any, what other things do you do while eating
How many ounces of water and other non-caffeinated fluids to you drink per day
How much caffeine (coffee, tea, chocolate, energy drinks) do you have per day
Is there anything you would like to change about your nutrition
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