Embody Training

 

Jake Westhoven, Jessi Westhoven, Personal Trainer, Physical Therapy Assistant

 

Insured (by NACAMS)

Licensed by the Physical Therapy section of the OTPTAT Board of Ohio

 

 

Health Questionnaire    

 

Today’s date: ­­­­­­­­­­______________

 

Name: ____________________     Age: ______

 

Address: _____________________________________Town: _________________ State:    ___    Zip: ______

 

Phone Number(s): ­­­­­­­­­­­­­­__________________________________________________________________________

 

Email (optional): ­­­­­­­­­­___________________________________________________________________________

 

Circle:    Male       Female – Any chance you are pregnant?      Yes / No

 

Any history of spinal injury or injury to a joint or muscle? ________________________________________________________________________________________ _________________________________________________________________________________________

 

Does it still affect you? Please describe: __________________________________________________________________________________________________________________________________________________________________________________

 

The following section will be completed by the trainer at the initial consultation:

 

Current Bodyweight: _______ lbs.

 

Current Body Fat Percentage _________ %

 

Height: ____ ft _____ inches

 

Resting Heart Rate: ______ bpm

 

What is your blood pressure? _______________       Unknown

 

BMI______________

 

Body Girths:

 

Waist                                      ______ inches

 

Hips                                        ______ inches

 

Legs                                        (left) ______ inches            (right) ______ inches

 

Upper Arm                            (left) ______ inches            (right) ______ inches

 

Forearms                               (left) ______ inches            (right) ______ inches

 

Calves                                     (left) ______ inches            (right) ______ inches

 

Shoulders                              ______ inches

 

Neck                                       ______ inches

 

Chest (men only)                  ______ inches

 

_________________________________________________________________________________________

 

What are your current health/fitness goals? _________________________________________________________________________________________

 

_________________________________________________________________________________________

 

What are the main reasons for your goals? _________________________________________________________________________________________

 

_________________________________________________________________________________________

 

           

 

Circle any symptoms of possible coronary or metabolic disease you have recently experienced:

 

Chest pain               shortness of breath   dizzy/fainting                  ankle swelling               heart palpitations       leg/feet cramping               heart murmur

 

Risk factors for CHD (Coronary Heart Disease), MI (heart attack), Stroke or hypertension (usually caused by atherosclerosis)

 

Do you smoke?     Yes          No

 

How much? ____________  per      day          week      month

 

Did you quit smoking less than 6 months ago?               Yes          No

 

Do you take:         Antihypertensive medications?        Yes          No

 

Are you currently taking Beta-blockers?     Yes          No

 

Do you get at least 30 minutes of moderate physical activity everyday?  Yes          No

 

Do you have:        Osteoporosis?      Yes          No

 

Osteoarthritis?     Yes          No

 

Do you suffer from back pain?          Yes:   Upper     Mid         Low                No

 

How often?          Rarely      Daily       Weekly     Monthly

 

Are you often stressed?     Yes          No

 

How does it physically manifest?      Headache              Stomach                 Sleepless               Irritable                  Other ________________

 

How many times do you get sick (common cold) per year?

 

1              2              3              4              More! _______

 

Do you have diabetes?       Yes:         Type I     Type II                    No

 

Are you taking any medications? List: _________________________________________________________________________________________

 

Do you eat low, moderate or high carbs?       Low         Mod        High

 

Do you eat low, moderate or high protein?    Low        Mod        High

 

Do you eat low, moderate of high fat?             Low         Mod        High

 

Do you eat a variety of foods (whole grains, dairy, lean meats, fruit & vegetables with limited fat/oils)?           Yes          No

 

How many calories do you need per day?      ____________ Kcal            (Men = Weight x 10.5; Women = Weight x 9.0)

 

How many calories do you eat per day?          ____________ Kcal

 

What level of importance do you place on exercise?

 

None      Low         Average           High        Essential

 

How often do you currently exercise? _________________________________________________________________________________________

 

What type(s) of exercise do you usually perform? _________________________________________________________________________________________

 

How many days per week do you want to commit to exercise?              

  1              2              3              4              5              6              7

 

How many minutes per day?

 

20 or less           about 30             45           60           an hour (+)

 

Rate your fitness (1-Poor, 5-Average, 10-Excellent):

 

Cardio-Respiratory  1              2              3              4              5              6              7              8              9          10

 

Strength                   1              2              3              4              5             6              7              8              9           10

 

Endurance               1              2              3              4              5              6              7              8              9           10

 

Flexibility                1              2              3              4              5              6              7              8              9            10

 

Power                      1              2              3              4              5              6              7              8              9           10

 

Body Composition   1              2              3              4              5              6              7              8              9           10

 

Self-Image               1              2              3              4              5              6              7              8              9           10

 

Other Comments:

 

_________________________________________________________________________________________

 

Informed Consent

 

Congratulations! You are making a commitment to invest in your health and well-being.

 

Please read the following and sign below to acknowledge your understanding and consent.

 

In order to assess your general health risk and tailor the training process to your individual needs, you will be asked questions about your, and your family’s, health history. Your privacy is respected. Your information will never be shared without your advanced written consent (except in the event of a medical emergency) and will not be used for any purpose other than adjusting your fitness training program and assessing your health risk as it pertains to your training. An educated trainer is better able to help you safely meet your goals.

 

In addition, as part of the assessment process, you will be asked to perform one or more tests to measure your level of fitness in several categories (i.e., cardiopulmonary, flexibility, strength, endurance and power). This testing can be as strenuous as exercise and will recur as needed to gauge your progress. Results are compared to norms and your prior results to measure success and keep you motivated.

 

The assessment process and training sessions include taking measurements and correcting form. Some measurements and/or correction of form may involve appropriate physical contact between you (the undersigned) and the trainer. You will be asked to give verbal permission before any physical contact is initiated.

 

Proper exercise is fundamental to a long, active and healthy life. The training sessions will involve mild, moderate or even strenuous exertion of your physical body. Intensity will be monitored by the trainer and customized to your health and tolerance. However, any physical activity can result in injury or death for reasons beyond the control of the trainer. Your signature below acknowledges you agree to be honest and forthcoming by reporting any medical history, conditions or injuries that may increase your risk of further injury, illness or death. Communicate whenever you are uncomfortable or in pain so your activity can be modified for your health and safety.

 

It is recommended that you eat a balanced, light meal or energizing snack 30-45 minutes prior to any workout and that you drink plenty of water all day to stay hydrated. When exercising, wear sneakers and loose-fitting and/or supportive clothing (as needed) in which you will be comfortable during the motions and positioning that are part of the training sessions.

 

 

 

Sign: _______________________    Print: ________________________        Date: _____________