Changing Lifestyles

New Client Form

Name

Date of Birth

Street Address

City/State/Zip

Phone#

Email

Gender MaleFemale
Height

Emergency Contact and Phone

How did you hear about us?

What days and times are you available to exercise?

Please answer all the following questions to the best of your ability and knowledge.

1.Has a physician ever told you that you have heart trouble?YesNo

2.Do you frequently have pains in your heart and chest area?YesNo

3.Do you often feel faint or have spells of severe dizziness? YesNo

4.Has a physician ever told you that your blood pressure was too high? YesNo

5.Has a physician ever told you that you have a bone or joint problem such as arthritis that has been aggravated or might be made worse by exercise? YesNo

6.Do you have a good physical reason not mentioned here why you should not follow an activity program even if you wanted to? YesNo

7.Are you over the age of 65 and not accustomed to vigorous exercises? YesNo

Have you ever had any of the following?

8.Heart attack or heart failure?YesNo

9.Heart Surgery?YesNo

10.Metabolic diseases?YesNo

11.A pacemaker or other heart device?YesNo

12.A heart valve or congenital heart disease?YesNo

13.Pulmonary disease?YesNo

14.A Stroke?YesNo

15.Coronary Artery Disease?YesNo

16.If you are a woman, are you pregnant?YesNo

17.Musculoskeletal or nerve problems?YesNo

Have you ever experienced any of the following?

18.Pain in your chest, neck or jaw?YesNo

19.Shortness of breath with mild exertion?YesNo

20.Palpitations, tachycardia, or irregular heart beat?YesNo

21.Orthopnea or Paroxsomal Nocturnal Dyspnea?YesNo

22.Intermittent claudication or thrombosis?YesNo

23.Ankle swelling?YesNo

24.Heart murmur?YesNo

25.Dizziness?YesNo

Indicate if you have had any of the following or if any apply to you:

26.Are you a male older than 45 years of age?YesNo

27.Are you a woman over 55 years of age or have had a hysterectomy or are postmenopausal?YesNo

28.Do you smoke or have quit smoking in the last 6 months?YesNo

29.Do you have blood pressure greater than 140/90?YesNo

30.Are you physically inactive or get less than 30 minutes of physical activity on at lest 3 day per week?YesNo

31.Do you have total cholesterol greater than 200 mg/dL?YesNo

32. You have a close male blood relative who had a heart attack before age 55 or a close female relative who had a heart attack before age 65YesNo

33.You have diabetes or take medication to control blood sugar YesNo

34.Take prescription medication YesNo

35.You are more than 20 pounds overweight.YesNo

Background Information

36.What is your current weight?

37.What do you consider a good weight for yourself?

38.What is the most you have ever weighed? How old were you?

39.Have you lost weight recently? YesNo If so, how much?

40.Have you gained weight recently? YesNo If so, how much?

41.Are your parents overweight? YesNo

42.Do you consider yourself overweight now? YesNo

43.How long have you been at your current weight?

44.How much weight do you want to loose now?

45.Do you have a hard time losing weight or maintaining your goal once you have lost the weight? YesNo

46.Besides your normal work or daily responsibilities, do you exercise more than 20 minutes per day? YesNo
47.If so, how many times per week?

48.If you are not overweight please skip to question 13.

49.Are there related factors to your being overweight?

Anger

Attending social svents

Boredom

Choosing the wrong types of foods (fried foods, sugar, sodas, desserts)

Depression

Emotions

Excessive Portion Sizes (Over Eating)

Nervousness

High Stress

Lack of Exercise

Snacking

Tired or Fatigued

Travel

50.Are you satisfied or dissatisfied with your appearance or weight? SatisfiedDissatisfied

51.Why do you want to reduce your weight?
Improve your appearance
Improve your Energy level or physical fitness
Improve you overall Health
Other

52.Have you followed any diet plans in the past? YesNo If so, which ones?

53.Did any of these diets work? YesNo

54.How long did you keep the weight off?

55.What was the best part of this diet?

56.Do you currently skip meals? YesNo If so which ones?

57.Do you snack through out the day? YesNo If so, on what?

58.Do you dine out frequently? YesNo If so, how often?

59.What type of food do you eat most frequently while dinning out (i.e. pizza, Italian, Mexican)?

60.On average do you eat fast, slow or moderate?

61.Do you take any nutrition supplements, vitamins or minerals? Yes