inSHAPE Health History and Client Information

First Name *

Last Name *

Email *

Phone *

Address (Street/Apt) *

City

State

Zip Code *

Age

Date of Birth

Height

Weight

Cholesterol (#/ low, normal, high)

Blood Pressure (#/ low, normal, high)

How did you hear about inSHAPE?

Check all goals that apply to you

Weight Loss Upper Body Tone Lower Body Tone Core/Abdominal Tone Functional Strength Better Balance Performance in an upcoming event Healthier Eating Habits Pain Reduction

Please list any additional goals:

Please indicate any timeline that you'd like to establish for your inSHAPE program:

Medical History (please indicate if you suffer from the following):

Anemia Arthritis Asthma or other respiratory illness Chest pain, heart disease, heart murmur, or other CVD Cramps or swelling in ankles and legs Diabetes Hernia Lightheadedness, fainting, dizziness, seizures, or epilepsy Stroke Ulcers Other

If you checked any of the above, please provide details below:

Check if you have suffered from any of the following orthopedic or muscular pain conditions in the last six months:

Head/Neck Back/Spine Shoulder/Arm/Wrist Hips/Groin Thigh/Hamstring Knee Ankle/Achilles/Foot

If you checked any of the above, please explain

Please list any medications you are on:

Please list any illness, hospitalization, or surgical procedure and the year in which they occurred:

Is there any other condition that might limit your participation in this program?

Please describe your typical nutrition/eating habits (breakfast/lunch/dinner/snacks):

Describe how much your weight has varied over the last 10 years, if at all?

How willing are you to accept recommendations for change in dietary plan?

In your opinion, how physically fit are you right now?

Unfit Below Average Average Above Average Very Fit

Do you currently exercise regularly?

If not, how long since you last did?

What types of exercise do you typically perform?

How many days per week?

Duration of a typical session?

Intensity of the sessions?

Please indicate the services that you are interested in:

In Home Personal Training Yoga Pilates Massage Therapy Nutrition Services

Date you would like to begin:

Days of the week that you can meet:

Monday Tuesday Wednesday Thursday Friday Saturday

Please check all that apply

Times of the day that you can meet:

Before work (6-8 AM) After work (6-8 PM) Late morning (8-Noon) Afternoon Weekend warrior: morning Weekend warrior: afternoon

Please add any other information we may need to schedule your sessions.

Please tell us a little about your workout space at home. Size, equipment, kids and/or pets running around...the more detail we have, the more prepared we will be when we get you started.

Wufoo