Client Pre-Screening Form

Name *

First

Last

Email *

Phone *

Date of Birth

DAY / MONTH / YEAR

Current Age *

What is your current age?

Occupation *

What is your Occupation?

Gender *

Please select one from the above.

Have you had a general medical check-up in the last 6 months? *

If YES, who is your GP?

Have you ever been told by your doctor to avoid any type of exercise or physical activity? *

If YES, please provide details

Do you have Type 1 or 2 Diabetes? *

If YES, please provide details

Are you on blood pressure medication? *

If YES, please provide details

Do you currently take any medication or have medical conditions that could influence your ability to exercise? *

If YES, please provide details

Are you a smoker? *

If YES, how many a day?

Do you drink alcohol? *

If YES, approximately how many standard drinks a week?

What best describes your weight history for the last 12 months? *

Decreasing
Stable
Increasing
Fluctuating

Do you have any current injuries? *

If YES, please provide details

Are you currently physically active? *

If YES, please provide details

Do you belong to a sporting group? *

If YES, please provide details

Do you have any history of injury associated with these areas? *

Soft tissue
Head
Neck
Shoulder
Lower Back
Upper Back
Hip
Knee
Ankle
Elbows
Feet
Other

Do you believe you have any problems with your current eating habits? *

If YES, please provide details

Do you drink tea/coffee? *

If YES, how many cups of each a day?

Do you drink soft drink regularly? *

If YES, how much per day? (This includes as mixed drinks)

Have you tried different diets in order to lose/put on weight? *

If YES, please provide details

How do you handle pressure? *

Rate yourself from 1 to 10

How much do you procrastinate? *

Rate yourself from 1 to 10

Do you stick to your goals until they are achieved? *

Rate yourself from 1 to 10

Do you wake up with energy? *

Rate yourself from 1 to 10

How well do you manage your time to achieve what you need to do? *

Rate yourself from 1 to 10

Do you follow through with what you say? *

Rate yourself from 1 to 10

If you could have one thing today what would it be? *

Time
Money
Family Time
Weight Loss/Gain
Energy
Happiness
Different Career
Work Less
Better Diet
Help more people

Please select one answer.

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