Personal Coaching Health
Today’s date:___________?Title: ODR.
__Mr. __Mrs. __Ms.?
Name: _______________ ________________
Gender: Male_______ Female________
Height: ________ Weight: _________?
Person to contact in case of emergency________________________
Medical History?Please indicate if any of these statements apply to you by placing
YES in the space provided
Birth date: ____________
Age: ______?Phone: (Home) ___________
Phone: (Work ____________ Phone: (Cell) _____________
(* past or current): PLEASE CIRCLE
1. History of heart problem (i.e.
Chest pain, heart murmur, or stroke)
2. Diabetes Mellitus?
3. Asthma, breathing, or lung
5. Cancer (other than skin)?
6. Seizures, seizure medication,
neurological problems, dizziness
7. High blood pressure?
8. Back problems, joint or muscle
disorder still affecting you?
9. Recent surgery (last 12 months)?
10. Hernia or any condition that may
be aggravated by exercise
11. Physician’s advice not to
12. History of high cholesterol
13. Family history of coronary heart
14. Do you smoke tobacco products? _______________________
15. Do you consume alcohol? _____________________________?
16. Do you take supplements of any
17. Are you on medication? ______________________________
18. Do you have joint problems that
might be aggravated by exercise?
19. Is stress from daily living an issue in
your life? _____________
L) _________________________________________________________ Shoulder(R, L)
Please Circle Any Areas of Pain, Tension, Injury, Or Restriction of
__________________________________________________________Please describe any special considerations or how your injury currently
affects your ability to function: (i.e. Illness or Injury)
Please talk with your doctor by phone
or in person before you start any new training program or have a fitness
assessment. Tell your doctor about your health questionnaire and which
questions you answered yes.
1. What are your concerns and goals? example:
fat loss, strength, power, muscular endurance, cardio fitness, flexibility,
agility, core stability or balance, Sports Performance Improvement, etc…
2. Why do you want to achieve these
goals? (Examples: general health, injury prevention/rehab, sport –specific
training, aesthetic reasons) __________________________________________________________
3. What areas do you want to
concentrate on or emphasize? (i.e. specific areas to strengthen, joint
stability, cardio or core conditioning) ____________________________________________________________________________________________________________________
4. How long has it been since you have
exercised regularly? (2 or more times/week).
5. Do you have experience with free
weights or functional stability training?
6. What type of cardiovascular
exercise are you familiar with?
7. If you are an experienced exerciser
or athlete, what exactly is your
8. Are there any exercises that are
contraindicated or not recommended by your physician or physical
9. How would you describe your level
of daily activities? Please check one. Light (office work)__ Moderate( Manual
labor)__ Heavy (construction)__
10. Stress (high=5, low=1) please
circle one.?Physical12345 Personal/Emotional12345 Mental/Career12345
11. Present method of handling stress:
12. Number of hours of sleep per night?_____________________
13. What is your available time and
frequency for exercise??
What days: M T W TH F?What times:
14. Any special considerations or
Personal Coaching Agreement
I am purchasing the services of FACT
Fitness and Robert Otis III and to design a program to aid in sports
performance improvement, and/or weight management to enhance my fitness goals.
I will not hold FACT Fitness or Robert Otis III personally liable for any
problems, illnesses or injuries that might occur due to a sudden change in my
eating or exercise habits. This program does not replace the advice of a
medical doctor, registered dietitian or other medical provider or treatment. I
have revealed any and all necessary information about myself to prevent any
possible complications to FACT Fitness and Robert Otis III.