Intake Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Height *

Weight *

Age *

Date of Birth *

Your doctor has told you that you have a heart condition and that you should only perform physical activity recommended by a doctor. *

Yes No

You have a bone or joint problem that could be made worse by engaging in physical activity. *

Yes No

You feel pain in your chest when you perform physical activity. *

Yes No

Is your doctor currently prescribing you medication for blood pressure issues or a heart condition? *

Yes No

In the past month you have had chest pain when you were not performing any physical activity. *

Yes No

Can you think of any other reason not to engage in physical activity at this time? *

Yes No

You lose your balance because of dizziness or have you ever lost consciousness. *

Yes No

If you answered yes to one or more of the boxes, consult your physician before engaging in physical activity. Tell your physician which statements you answered "yes." After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

The most important reasons why I am interested in this program are: *

My main goals for myself are: *

To accomplish these goals, I will have to do these three things: *

A few possible obstacles to making these changes and how I could handle them are: *

The most important reasons why I am improving my nutrition are: *

To accomplish these goals, I will have to change these three eating behaviors: *

Other people who could help me with these changes are: *

My main nutrition goals for myself are: *

I have had a hard time sticking to healthy eating in the past because: *

I know my plan is working when I: *