Intake form

New clients

Name

First Name

Last Name

Age

Gender

Phone

(###)

###

####

Next of kin & contact tel no

Physical Activity

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Chest pain

Do you ever experience chest pain when doing physical activity?

Balance

Do you ever lose balance or conciousness due to dizziness?

Bones & joints

Do you have a bone or joint problem (eg back, neck or hip) that could be made worse with physical activity?

Medication

Is your doctor currently [rescribing you medication (Eg water pills) for blood pressure or a heart condition?

Other

Do you know of any other reason why you should not do physical activity?

If yes, please provide details