Client Intake Form

Client Details

Name

Date

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Physical Activity Readiness Questions

Please answer YES or NO to each question based on how you feel today:

Are you currently taking prescribed medication for blood pressure or a heart condition?

YesNo

Are you pregnant?

YesNo

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

YesNo

Do you feel pain in your chest when you do physical activity?

YesNo

In the past month, have you had chest pain when you were not doing physical activity?

YesNo

Do you lose your balance because of dizziness or ever lose consciousness?

YesNo

Do you have a bone or joint problem that could be made worse by physical activity?

YesNo

Is your doctor currently prescribing drugs for blood pressure or a heart condition?

YesNo

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

YesNo

If yes, please explain:

Consent

Printed Name

Signature

Date

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