Fitness Client Intake – Rowed to Fitness

Name

First

Last

Client Phone Number

Client Email

Emergency Contact

First

Last

Emergency Contact Phone Number

Physical Activity Readiness Questionnaire

We recommend consulting with a doctor prior to starting any physical activity program.

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

Yes
No

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

Yes
No

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

Yes
No

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

Yes
No

PLEASE LIST CONDITION(S) BELOW:

Are you currently taking prescribed medications for a chronic medical condition?

Yes
No

PLEASE LIST MEDICATIONS AND CONDITION(S) BELOW:

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

Yes
No

Has your doctor ever said that you should only do medically supervised physical activity?

Yes
No

If you answered NO to all of the questions above, you are likely cleared for physical activity.

If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. A medical release or note from your physician may be required in order to begin program.

Lifestyle Questionnaire

Basic information to help build your initial program.

Why do you want a fitness or indoor rowing coach?

How long have you consistently exercised? (Past and/or current)

If you are currently exercising, how many days per week?

What are your short term goals for fitness or/and rowing?

What are your long term goals for fitness or/and rowing?

What is your prefered time to workout during the day?

What is your current training or exercise routine or program like, or what have you done in the past?

What equipment do you have available for workouts at home or at another fitness facility?

Do you have and use a chest strap heart rate monitor?

Yes
No

How many hours of uninterrupted sleep do you get each night?

4 or less
5-6
7-8
More than 8

What time do you go to sleep?

Are you currently or have you ever followed a nutrition program? If so, what worked, and what did not and why?

How much water do you drink per day?

6 cups or less
7-8 cups
8 or more cups

How would you rate your energy level throughout the day (1-10)?

List your top weekly commitments (ex. family, work, fishing...) in order of importance, and include working out and where it falls, or would fall, in the list.

What would your ideal fitness or indoor rowing program look like?

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