Health & Goals Questionnaire Name * First Name Last Name Pronouns Date of Birth * MM DD YYYY Age * Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Relationship * Emergency Contact Phone Number * (###) ### #### How did you hear about Luisa Noelle * Do you have a gym in your building * Yes No HEALTH Height * Weight * Profession Has a physician ever diagnosed you as having high blood pressure {>160/90} or are you currently on any high blood pressure medication? * Yes No Is your cholesterol higher than 240 mg/DL? * Yes No Do you smoke? * Yes No If so, at what age did you start? How many cigarettes per day? Do you consume alcohol? * Yes No If yes, what type of alcohol? How many beverages per week? Do you have diabetes? * Yes No Are you pregnant or do you think you might be pregnant? * Yes No Has anyone in your immediate family suffered from coronary or atherosclerotic disease prior to age 55 * Yes No Has your doctor ever said you have heart trouble, coronary heart disease or high blood pressure? * Yes No Do you frequently experience pain or discomfort in the heart or heart area? * Yes No Do you suffer from shortness of breath at rest or upon mild exertion? * Yes No Do you have difficulty breathing? * Yes No Do you suffer from dizziness or fainting? * Yes No Do you suffer from swollen ankles due to circulation problems or metabolic condition? * Yes No Do you experience pain in your limbs when exercising or moving? * Yes No Are you on any medications that induce light headedness or dizziness? * Yes No Do you have any allergies? * Yes No If so, what are your allergies? Do you consider your life stressful? * Yes No If so, how stressful? (1-10 and 10 being most stressful) Do you practice stress management?* * Yes No If so, what methods do you use? Do you have any current or past injuries, aches or pains that we should be taken into consideration when designing your program? * Do you currently exercise? * How would you rate your eating habits? * 1 (significant room for improvement) 2 (some room for improvement) 3 (I’m a super star!) How willing are you to make the needed tweaks to your eating habits to support our work for your goals? * 1 (it will be very hard for me) 2 (A challenge I am ready to work on) 3 (I’m all in!) GOALS What is the main reason that compelled you to start this training? * How do you picture yourself 3 months from now physically? * How do you picture yourself 3 months from now emotionally? * How do you picture yourself one year from now physically? * How do you picture yourself one year from now emotionally? * What are the primary goals you would like to reach with your exercise program (general strength, fat loss, flexibility, sports training, improve a specific body part, sport/skill, low back strength, etc. Please be as specific as possible): * How ready are you to do what it takes to commit to these goals? * What do you foresee as your biggest challenge? * If you had to give 3 keywords you need to feel in order to be successful, what would they be? * our ideal & amazingly fun fitness-training program would include...(i.e. swimming, boxing, yoga, strength training): * What intensity do you prefer for your workouts? * Low Moderate Intensity Intense Very Intense New York New You Policy Cancellations, Billing and Fees – Please read thoroughly & initial * Sessions: Cancellation must be made a minimum of 24 hours in advance to avoid full session charge Session Reservations & Expiration- Please initial * Clients may cancel with no charge 24 hours in advance by calling or emailing only Please read thoroughly & initial * I hereby acknowledge that I understand there are risks involved in participating in any exercise program & that I am in good physical condition. My medical provider has advised that I may participate in the physical exercise program that we have discussed. I assume all risks associated with a physical exercise program, other than gross negligence on the part of Luisa N. Howell. I acknowledge that I have been advised to have a physical examination with my doctor prior to beginning any exercise or training program and that I have been advised to have regular medical physicals as recommended by my doctor. I shall advise Luisa Howell of any change in my medical condition that could affect my exercise program. I understand that I have assumed the risk of injury on account of the exercise equipment or any medical condition that I have not disclosed in writing to Luisa Howell. Luisa Howell provides personal training and yoga services and does not possess medical expertise. Medical opinions and information should be obtained from qualified health care providers only. Name * First Name Last Name Do you certify that all the information provided is true? * Yes Today's Date * MM DD YYYY Thank you! Your profile has been submitted. We will get back to you shortly! Truth. Effort. Courage.
