Client Health Questionnaire

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Emergency Contact Name

Emergency Contact Relationship

Current Health Status: (Any known medical conditions. Please list them down.)

Medications: (List any medications being taken)

Allergies: (Yes or no, which if applicable)

Sleep Patterns: (Average hours per night, quality of sleep - poor, okay, great)

Stress Level: (On a scale of 1-5 . 5 is the highest)

Current Fitness Routine: (Describe typical weekly activities - not currently active, active 1-3 times per week, active 3+ times per week)

Fitness Goals: (What is your short-term fitness goal? What is your long-term fitness goal?)

Challenges in Achieving Fitness Goals: (Yes or no. If yes please share)

Past Injuries or Physical Limitations: (Yes or no. If yes, please share)

Current Eating Style: (Options: eat anything, vegan/vegetarian, keto, gluten-free or other)

Nutritional Goals: (What are your nutrition or body goals?)

Challenges with food: (Yes or no. If yes please share)

Food Preferences and Restrictions: (yes or no. If yes please share)

Current Weight:

Body Fat Percentage: (If known)

Blood Pressure:

A1C Levels: (If diabetic or pre-diabetic)

Cholesterol Levels: (If known)

Occupation: (Include work hours and nature of work)

Leisure Activities: (List: Hobbies, interests)

Alcohol Consumption: (none, socially, 1+ time per week)

Tobacco Use: (none, socially, 1+ time per week)

Caffeine Intake: (options: coffee, soda, tea)

Main Reason for Working with a Coach:

What You Hope to Achieve:

Any Other Relevant Information

Physical Activity Readiness Questionnaire (PAR-Q)

Has your doctor ever said you have a heart condition and you should only perform physical activity that a doctor recommends?

Yes

No

Do you feel pain in your chest when you perform physical activity?

Yes

No

In the past month, have you had chest pain when you were not performing any physical activity?

Yes

No

Do you lose your balance because of dizziness, or do you ever lose consciousness?

Yes

No

Do you have a bone or joint problem that could be made worse by activity?

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or a heart condition?

Yes

No

Do you know of any other reason why you should not engage in physical activity?

Yes

No

If you have answered "Yes" to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered "Yes" to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Consent and Acknowledgement:

I hereby confirm that the information provided is accurate to the best of my knowledge and understand that it will be used to tailor my coaching sessions to my individual needs.

Client Health Questionnaire

Physical Activity Readiness Questionnaire (PAR-Q)

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