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Home » Rise For Life Health Background

Rise For Life Health Background

Please complete the following form with as much information as possible. All of the information below is kept private and not shared with anyone outside of Rise Fitness coaching staff without prior permission.

Rise For Life: Background Questionnaire

Δ

First Name

Last Name

DOB

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

In case of emergency, notify:

Phone number

Current Physician

Physician Phone

Describe your fitness experience and/or current activity level

Are you ambulatory?

Yes

No

Describe any injuries/limitations and/or relevant medical history for consideration in fitness (including vision impairment, difficulty hearing, use of cane or assistive device, oxygen, etc.)

Do you have any orthopedic conditions (including arthritis)?

Yes

No

If you answered yes, please explain:

Have you ever experienced chest pain associated with exercise or stress?

Yes

No

If you answered yes, please explain:

Have you ever experienced shortness of breath with or without exercise?

Yes

No

If you answered yes, please explain:

Have you experienced fainting or light – headedness?

Yes

No

If you answered yes, please explain:

Are you under the care of a physician, chiropractor, or other healthcare professional for any reason?

Yes

No

If you answered yes, please explain:

Are you taking any medications?

Yes

No

If you answered yes, please explain:

Please Indicate if you have any of the following conditions (Select all that apply)

Asthma

Respitory/Pulmonary Conditions

Diabetes Type 1

Diabetes Type 2

Epilepsy

Osteoporosis

Coronary Artery Disease

Heart Attack History

Hypertension

Stroke History

Pacemaker

What are your personal goals for training?

Is there anything else you would like for us to know before you start training?

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