Client Consultation Form

Section 1 – Personal Information

Name

First

Last

Date (DD/MM/YY)

DOB (DD/MM/YY)

Number

Email

Emergency Name and Contact

Section 2 – Health Screening

Does anyone in your family have a history or diagnosis of heart disease?

Does anyone in your family have a history or diagnosis of diabetes?

Smoking History

Currently

Quit in the last 6 months

Smoke free for over a year

Never

Have you had any injuries in the last 3 months, or anything that might hinder your exercise progression?

Do you have any other heredity condition?

Please note that if any of the above are yes and you frequently feel symptoms/side effects, you may have to visit your GP for medical clearance to exercise.

On a scale of 1-10 how do you rate your current health?

On average how many hours sleep do you get?

4-6

6-8

8+

Section 3 – Lifestyle Questionnaire

How do you rate yourself on this chart?

Pre-contemplation: I have no intension of making a change in the next 6 months

Contemplation: I intend to make a change in the next 6 months

Preparation: I intend to take action in the next month and have taken some steps to change

Action: I have started to make a change

Maintenance: I have made a change for more than 6 months

Relapse: I have returned to pre-contemplation behaviour

What is your current occupation?

What is the activity level of your occupation?

Do you currently exercise?

Yes

No

If yes, what exercise do you carry out?

How many hours a day are you sedentary (not including sleep time)

0-4

4-8

8-12

12+

What days of the week are you able to have sessions?

What times of day are you able to have sessions?

PLEASE NOTE CURRENTLY: Monday, Tuesday and Wednesday I only have slots early morning or daytime. Thursdays are evenings or early morning only and Friday early mornings only – all time slots available can be discussed.

Please provide 3 exercises that you enjoy and would like in your programme

Please provide 3 exercises you do not enjoy and would prefer were not in your programme

Using low. medium or high, rate your intake of the following dietary choices:

In order of urgency what are the top three reasons for requiring a PT?

What are the 3 main barriers as to why you haven’t achieved your fitness goals?

Using low, medium or high, rate your intake of the following dietary choices:

Processed chilled food

Low

Medium

High

Processed frozen food

Low

Medium

High

Take away meals

Low

Medium

High

Alcohol Intake

Low

Medium

High

Snacks (Inc. Chocolate)

Low

Medium

High

Salt Intake

Low

Medium

High

Protein Intake

Low

Medium

High

Vegetable Intake

Low

Medium

High

Fruit Intake

Low

Medium

High

Water Intake

Low

Medium

High

Wholegrain Foods

Low

Medium

High

Based on the above food questionnaire, which 3 would you be willing to change/improve, to help assist with your physical goals?

Do you regularly skip meals?

Yes

No

If yes, how many per week? (on average)

Section 5 – Programme Strategy – FOR PT COMPLETION