Pre-Consultation Form

Take The Exit Towards Better Habits
Pre-Consultation Form
Name *

First Name Middle Name Last Name
Age *
Current Body Weight (lb or kg)
Height
Gender *

Male Female

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail *
Phone Number *

- Area Code Phone Number
Tell me Your Fitness Goals. What do you want to see yourself doing? Imagine your ideal self. *
THE PHYSICAL ACTIVITY READINESS QUESTIONNAIRE
Do you feel pain in your chest when you do physical activity? *

Yes No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes No
In the past month, have you had chest pain when you were not doing physical activity? *

Yes No
Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes No
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? *

Yes No
If YES, please explain.
Do you have any physical injuries? *

Yes No
If YES, please explain.
MEDICAL HISTORY

Mark All True Statements
You have had:

a heart attack heart surgery cardiac catheterization coronary angioplasty heart valve disease heart failure heart transplantation congenital heart disease pacemaker/implantable cardiac defibrillator/rhythm distrubance
You Experience:

chest discomfort with exertion unreasonable breathlessness dizziness, fainting, blackouts ankle swelling unpleasant awareness of a forcefull or rapid heart rate
You:

have diabetes or are prediabetic have high blood pressure have asthma or other lung disease have burning or cramping sensation in your lower legs when walking short distance have musculoskeletal problems that limit your physical activity have concerns about the safety of exercise are pregnant
Are you taking prescription medication? Please state. *
Is your blood pressure greater than 140/90bpm? *

Yes No I don't know, but my doctor said my blood pressure is high I don't know my blood pressure
Is your cholestrol level greater than 200mg.dL-1? *

Yes No I don't know, but my doctor said my cholestrol is high I don't know my cholestrol
Do you have a close blood relative who has had a heart attack or heart surgery before age 55(father or brother) or age 65 (mother or sister)? *

Yes No I don't know
HABITS
Do you binge eat? If so how many times a month? *
How many glasses of juice and cans of soft drink do you drink per week? *
How many servings of vegetables do you eat per week? *
Do you drink alcohol? If so, how many drinks a week? *
Do you smoke? If so, how many packs a week? *
Do you have any food allergies or intolerance? *
Do you take any supplements? *
Have you in the past experienced weight loss fluctuations? Please explain. *
Do you experience feeling low energy throughout the day? Please explain. *
Foods you don't enjoy eating. *
Foods you have high cravings for. *
On average, how many hours of sleep do you get? *
How often do you eat out? *
Do you skip meals? Why? Please explain. *
In what situations do you get cravings for sugar? *
What type of job do you have? *

Sedentary (Mostly sitting all day) Standing most of the time Physical
Typical Eating Pattern
What Time do you eat breakfast? Leave blank if not applicable.

: Hour Minutes
FOODS YOU COMMONLY EAT FOR BREAKFAST: *
What time do you eat a Mid-Morning snack? Leave blank if not applicable.

: Hour Minutes
FOODS YOU COMMONLY EAT FOR MID-MORNING SNACK: *
What Time do you eat lunch? Leave blank if not applicable.

: Hour Minutes
FOODS YOU COMMONLY EAT FOR LUNCH: *
What Time do you eat an afternoon snack? Leave blank if not applicable.

: Hour Minutes
FOODS YOU COMMONLY EAT FOR AFTERNOON SNACK: *
What Time do you eat dinner? Leave blank if not applicable.

: Hour Minutes
FOODS YOU COMMONLY EAT FOR DINNER: *
What Time do you eat post-dinner snack? Leave blank if not applicable.

: Hour Minutes
FOODS YOU COMMONLY EAT FOR POST-DINNER SNACKS: *
BETWEEN WHAT TIME OF DAY ARE YOU LOOKING TO TRAIN?
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Take The Exit Towards Better Habits

Pre-Consultation Form

THE PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

MEDICAL HISTORY

HABITS

Typical Eating Pattern