Believe It. Do It. Live It.


Pre-Assessment Form

General Info
First Name:
Last Name:
Medical History
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?
Have you ever had any surgeries?
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart diesase, coronary artery disease, hypertension (high blood preasure), high colesterol, or diabetes?
Are you currently taking any medication?
General History
What is your current occupation?
Does your occupation require extended periods of sitting?
Does your occupation require extended periods of repetitive movements?
Does your occupation require shoes with a heel or dress shoes?
Does your occupation cause anxiety or mental stress?
Do you partake in recreational activities (golf, tennis, skiing, etc.)?
Do you have any hobbies (reading, gardening, working on cars, etc.)?
Physical Activity Readiness
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the last month, have you had chest pain when you are performing any physical activity?
Do you lose your balance because of dizziness or do you lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medicatin for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?
*If you have answered "Yes" to one or more of the questions in this section, consult your physican before engaging in physical activity. Tell your physican which questions you answered "Yes" to. After a medical evaluation, seek advice from your physican on what type of activity is suitable for your current condition
Tell me about your physical activity
What experiences with physical activity have you had in the past?
What has worked for you to help you stick with an exercise progam?
What has worked the least to make you want to stop that program?
During the last 6 months, what has kept you from exercising?
How have you kept up with an exercise program when you have had a busy schedule: such as work, travel, vacation, family, and holidays?
Be goal driven!
What is your dream accomplishment?
We all have dreams and goals are the best way to acheive them. So list your goals, next to the questions listed, that you would like to acheive to be a healthier, stronger, and more active you.
What do you want to accomplish in the next 6 months?
What resources are needed to accomplish this goal(s)?
What do you need to accomplish on a daily basis to reach this goal(s)?
What coud possibly hinder you in accomplishing this goal(s)?
I want to help you in anyway I can. Please list the ways I can help you accomplish your goal(s). As you progress we can adjust them and I can't wait for that to happen.

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