FACT Fitness
Advocare Nutrition Distributor
www.advocare.com/170522291

Call Us (408) 430-6624

 

Personal Coaching Health

Screening Questionnaire

Personal Information

Today’s date:___________?Title: ODR. __Mr. __Mrs. __Ms.?

Name: _______________ ________________

Address: ____________________________________?

City: _______________________________________?

Email: ______________________________________ Occupation:_________________________________?

Gender: Male_______ Female________

Height: ________ Weight: _________?

 Person to contact in case of emergency________________________

Tel:______________________

Physician’s Name: __________________________

Tel: ______________________________________

 

 

 

 

 

 

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 problems?

4. Allergies

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 exercise?

12. History of high cholesterol

 

 

 

13. Family history of coronary heart disease? _________________

14. Do you smoke tobacco products?  _______________________

15. Do you consume alcohol?  _____________________________?

16. Do you take supplements of any kind?  __________________

 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? _____________

Skeletal Injuries

Back______________________________________________________Neck______________________________________________________Head______________________________________________________Knee(R, L) _________________________________________________________ Shoulder(R, L) ______________________________________________________?

Other injuries: ______________________________________________________?

 

 

 

Please Circle Any Areas of Pain, Tension, Injury, Or Restriction of Movement

Surgery: __________________________________________________________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.

 

 

 

 

 

Goals

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) ____________________________________________________________________________________________________________________ ____________________________________________________________________________

 

 

 

 

Fitness History

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   current program?___________________________________________ _____________________________________________________________________________

8. Are there any exercises that are contraindicated or not recommended by your physician or physical therapist?__________________________________________________ ___________________________________________________________________________

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: AM__________ PM___________?

14. Any special considerations or requests? _________________________________________________________ _____________________________________________________________________________________________________________________________________________

 

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.

Signature______________________________________________________ Date _____________________

 


 

Foundation Athletic Coaching Techniques