Metabolic Client Intake – Rowed to Fitness

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Client Phone Number

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Emergency Contact

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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.

Signature

Please sign to verify you have read and answered the above answers correctly.

Lifestyle Questionnaire

Basic information to help build your initial program.

Why do you want a Resting and/or Active Metabolic Rate test?

What is your prefered time to conduct the test during the day?

Please note that a Resting Metabolic test requires a minimum of 6 hours fasting and an Active Metabolic test requires a minimum of 4 hours testing. Both tests require that you did not do strenuous exercise within the previous 24 hours.

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

If you are not currently training or do not have an exercise program, are you interested in finding out what we can do to help you with one?

Yes
No
Maybe

Are you interested in a customized nutrition program based on your Metabolic test results and personal preferences?

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