Provide your full name, email, and best phone number:

Your Height & Current Weight:

What is your occupation? Does the current complaint or condition you're seeking coaching for interfere with your work?

Do you participate in any recreational activities (golf, tennis, skiing, etc.)? If yes, please explain.

Please list any current or previous discomfort, pain, or injuries (ankle, knee, hip, shoulder, back, neck, etc.) 
Please explain and include timing.

What is the discomfort, pain, or injury preventing you from doing now?
What could you do prior to this that you can no longer do, and that you still Want to do?

Please list any previous surgeries with their explanation and timing.

Have you ever been diagnosed with a chronic disease, such as heart disease, hypertension, diabetes, etc.? If yes, please explain

Have you ever been diagnosed with, or suspected you have, Scoliosis (a curve in the spine)?

Please list medications you currently take:

In times of stress, what is your PRIMARY "go to" for calming (choose one):

Is there anything else you would like to share with your trainer regarding your health history?

Please provide emergency contact name and phone number.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by your doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Do you know of any other reason why you should not do physical activity?

In 2-3 sentences, what is your definition of Health and Wellness Success? What does it look/feel like? What will you achieve?

List Your Accomplishments in the last 5 Years:

What are your primary concerns at this time / what are you unable to do?

What are your weekly exercise and/or nutrition goals?

Please be specific and include numbers / timing.  For example:

- I will exercise 4x per week at 7am on M, T, TH, Sa.

- I will perform my drills 5x daily at 6am, 9am, 12pm, 6pm, and 9pm.

What has worked before to help you move closer toward your goals?

What has not worked before, or what has gotten in your way?

What would success look like in 3-6 months, if we were to work together?

These are the strengths I have to accomplish my goals:

Please list additional specific activities you would like to also focus on?  (walking, jogging, golf, skiing, sleeping, stair climbing, carrying heavy loads, racquet sports, squatting, house work, etc.)

Please list gym equipment to which you have access.

If you belong to a gym, please type "gym."

What are 1-2 health & wellness related topics you would like to learn more about?

Be as specific as you wish as this will help us further personalize your program.

What are 1-3 motivation triggers for you?

What type of music would you like to hear during your sessions?

How many workout sessions per week will you commit to?

Choose your weekly goal and keep it realistic.  Consistently working out 3 days per week for example will generate longer term results than sporadic workouts.

By typing my name below, I certify that the information provided in this Health History and PAR-Q is true and complete to the best of my knowledge.

I understand that physical exercise involves inherent risks, including but not limited to muscle strains, joint injuries, or cardiovascular distress. I voluntarily assume these risks and hereby release Sheryl Teitelbaum and Living4Health from any and all liability, claims, or causes of action arising out of my participation in this program. I also agree to notify my trainer immediately of any changes to my medical status.