Getting To Know You – Priority One

Name

First

Last

Address

City

State/Province

Zip/Postal

Email

Phone

Do you currently exercise regularly?

Yes

No

Do you have a strength training routine?

Yes

No

If yes, how many minutes per session?

How many times per week?

Do you do any cardio/aerobic exercise?

Yes

No

If yes, how many minutes per session?

How many times per week?

What is your aerobic activity of choice? (Ex: walk, bike, swim, elliptical, etc.)

Do you perform an activity/exercise/sport which requires repetitive motion?

Yes

No

If yes, please list. (Ex: golf, tennis, baseball, soccer, etc.)

I am most interested in improving my... (choose all that apply)*

Please list any special conditions which may impact your activity. (Ex: injury, surgery, illness, medications, pregnancy, etc.)

List any previous and/or upcoming surgeries, regardless of how much time has passed.*

Please share some details about your average day:

On average, how many hours do you sleep each night?

Please list your ADLs (Activities of Daily Living) in order of frequency/demand.

Sitting

Driving

Standing

Walking

Lifting

Building

Kneeling

Do you experience any particular recurring pain or soreness not referenced above?

Yes

No

If yes, where?

What brings on this discomfort?

Most of my meals are... (check all that apply)

How many 8 oz. cups of water do you estimate you drink each day?

How often do you consume caffeinated beverages? (cups per day)

My ideal exercise routine would be _______ minutes long.

I would do my ideal exercise routine _______ days a week.

Is there anything else you would like to share/address?