consultation form Home Contact Us Personal DetailsNameGenderMaleFemalePhoneEmailAddressOccupationDate Of BirthEmergency contact (ICE)ICE PhonePersonal and/or Family IllnessesHave you or your direct family had any of the following? (select all that apply)DiabetesHeart ProblemsHigh / Low Blood PressureStrokeAsthmaChest painArthritisEpilepsyOsteoporosisHigh CholesterolSmokingDo you or have you ever smoked?YesNo# per dayIf you stopped smoking, how long ago did you stop?Physical activity profileActivity level (select one)ActiveInactiveHow intensely? (select one)LightModerateVigorousIf active, how frequently?AgeAPMHRIs there anything else that may affect you exercising?Physical profile (trainer use only)WeightHeightWaist girthHip girthMedications and blood pressureDo you take any pills, tablets, medicine or medication?YesNoIf yes, please describeBlood Pressure (BP)Injury ProfileHave you ever injured any of the following areas of your body? (select all that apply)Head/NeckBack/TorsoShouldersArmsHands / WristsHipsUpper LegsKneesLower LegsAnkles / FeetGoal SettingI want to seeMore tone/shapeMore muscleLess body fatI want to feelMore energeticHealthierLess stressed & more relaxedI want to beFitterStrongerHappierBarriers, Support and InterventionWhat factors have helped you previously achieve your goals? (people, scheduling, support networks)What factors do you think could get in the way of achieving your goals?How likely is it that these factors will affect your progress?What support are you expecting from your trainer?Which phrase best describes your motivation levels?I am self-motivatedI find exercise easier to stick to if I have a partnerI find exercise easier with regular appointmentsI usually experience some problems staying motivatedI need constant motivationLifestyle (select the number that best represents you)Sleep quality (10 = quality sleep, 8+ hours, uninterrupted)12345678910Energy / Fatigue levels (10 = consistent energy throughout the day, no crashing)12345678910Stress levels (1 = happy and content, never anxious, look forward to my day)12345678910Nutrition (10 = plenty fruit and vege and water, minimal processed foods, feel great after each meal)12345678910Exercise History If you are currently exercising...What activities are you doing?What do you like or dislike about them? (environment, intensity, equipment...)If you have previously exercisedWhat activities did you do?What did you like or dislike about them? (environment, intensity, equipment...)Exercise PreferencesHow often would you ideally like to train?On a scale of 1 to 10, how hard would you like to exercise (on average, 10 being extremely hard)?On average, how long would you like to exercise for?What is your preferred workout style and or would like to try? (please select)WeightsCardioHigh Intensity Interval trainingYogaCircuit trainingPrescription recommendations (to be completed by the trainer/consultant)FrequencyIntensityTimeTypeStage 3 referral recommendations and considerationsTrainer notes Send Message
