Initial Consultation Health Screening

Medical Questionnaire
Do you smoke?
- yes
- no
If so, how much per day?
Has your doctor ever said your blood pressure was too high or too low?
- yes
- no
Have you (or a family member) ever been told that you have diabetes?
- yes
- no
Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc.)?
- yes
- no
If so, what?
Has your doctor ever told you that your cholesterol was too high?
- yes
- no
Do you have any injuries or orthopaedic problems (bad back, bad knees, etc.)?
- yes
- no
Do you have any injuries or orthopaedic problems (bad back, bad knees, etc.)?
- yes
- no
If so, what?
Do you have stiff or swollen joints?
- yes
- no
If so, where?
Do you have tension or soreness in any area?
- yes
- no
If so, what?
Are you taking any prescribed medications or dietary supplementation?
- yes
- no
If so, what?
Do you ever have any problems sleeping?
- yes
- no
If so, what is the cause?
Are you pregnant or post-partum less than six weeks?
- yes
- no
Do you have any other medical conditions or problems not previously mentioned?
- yes
- no
If so, what?
Have you ever been advised by a doctor or physician not to perform any type of exercise or activity?
- yes
- no
If so, why?

Goals / Target Setting
What are your General Goal goals?
- Weight Loss/Fat Reduction
- Fitness and Stamina
- Flexibility
- General Health
- Injury recovery
- Sports Performance
- Injury prevention
- Posture
- Strength
- Weight Gain
- Other
What are your specific goals and time scales
Description / goal set Target date Importance 1 to 10
About your long-term goal:
What method of assessment will you use to measure your success?
How much time can you commit to this process?
Are you prepared to modify your nutrition and lifestyle habits to meet these goals?
What is your level of belief that you can meet this goal on a scale of 1 to10
What has stopped you from starting earlier and is it still an issue?

Training Pre-Requisites
How often do you wish to train with your trainer?
How often do you wish to train on your own?
Would you be prepared to perform home exercise / stretch routines?
Do you have someone that would like to train with you or may benefit from our services
Name:
Contact:
Where did you find out about Core Results?
INFORMED CONSENT

I acknowledge, to the best of my ability, that I have read and answered the above fully and truthfully and that I am in good health and have no known medical problems that would restrict my ability to participate in this exercise program. I am aware of my responsibility to consult with my doctor or physician regarding my medical fitness prior to engaging in exercise. I understand that should my personal circumstances change, I must inform my Trainer or Core Results immediately.
Client signature*
Date
MM slash DD slash YYYY
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Description / goal set	Target date	Importance 1 to 10

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