Email * Phone Date of Birth Emergency Contact Name and Phone #: Exercise What exercise activities do you currently take part in (e.g., running, weightlifting, group exercise, etc.)? How many days per week do you get at least 60 minutes of moderate-intensity exercise? What Is/Are Your Current Fitness or Health Goals Nutrition On a scale of 0 to 10, do you consider your overall diet to be healthy? Are you currently following any kind of diet? If so, what diet and for what reason(s)? How would you describe your current eating habits? How many alcoholic drinks do you consume per week? Lifestyle Do you feel like you get enough sleep and wake up feeling rested each day? On average, how many hours of sleep do you get every night? On a scale of 0 to 10, how would you rate your average level of stress? What techniques do you currently use to manage your stress levels? Do you smoke tobacco or use a vaporizer alternative? Occupation What is your occupation? Does your occupation require extended periods of sitting? (If YES, please explain.) Does your occupation require repetitive movements? (If YES, please explain.) Recreation Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.) Do you have any additional hobbies (gardening, fishing, music, etc.)? (If YES, please explain.) Medical Please list out any past musculoskeletal injuries: Please list out any past surgeries: If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity? Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonary disorders, hypertension, diabetes, or cancer)? (If YES, please explain.) Are you on any medications, and if so, have you received clearance from your doctor to take part in physical activity? Additional Notes Is there anything else that you would like to add that is not listed above?