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Personal Coaching Intake Form
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Personal Coaching Intake Form
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Name
*
First
Last
Email
*
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
*
No
Yes
Do you feel pain in your chest when you perform physical activity?
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No
Yes
In the past month, have you had chest pain when you were not performing any physical activity?
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No
Yes
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
No
Yes
Do you have a bone or joint problem that could be made worse by change in your physical activity?
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No
Yes
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
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No
Yes
Do you know of any other reason why you should not engage in physical activity?
What is your current occupation?
Does your occupation require extended periods of sitting
*
No
Yes
Does your occupation require repetitive movements? If YES, please explain.
Does your occupation require you to wear shoes with a heel (e.g., dress shoes)?
No
Yes
Does you occupation cause you mental stress?
No
Yes
Do you partake in any physical activities (golf, skiing, etc.)? If YES please explain.
Do you have any additional hobbies (reading, video games, etc.)? If YES please explain.
Have you ever had any injuries or chronic pain? If YES please explain.
Have you ever had any surgeries? If YES please explain.
Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? If YES please explain
Are you currently taking any medication? If YES please explain.
Please include any additional information that we should know about you.
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