Name * First Name Last Name Email * Phone (###) ### #### Preferred form of contact Primary Care Physician Name First Name Last Name Address Phone and/or email Preferred form of contact Past Medical History Have you ever been told by a doctor that you have or had heart problems, an abnormal EKG, or had a heart attack or stroke? Heart problems Abnormal EKG Heart attack Stroke None Have you ever had coronary by-pass surgery, angioplasty, or any other type of heart surgery? Yes No Have you ever had difficulty breathing or become short of breath with mild or light exertion? Yes No Do you have a history of diabetes, kidney or liver disease? Diabetes Kidney disease Liver disease None Have you ever experienced irregular heartbeat (arrhythmia) or been diagnosed with a heart condition or disease? Arrhythmia Heart condition/disease None If you answered yes to any of the above questions, please provide additional information here: Please list all past injuries, illnesses, surgeries and hospitalizations: Current Medical History Do you currently experience or have any of the following: * Pain or discomfort in the chest or surrounding areas that occurs when you engage in exercise or physical activity? Shortness of breath with activity or at rest? Unexplained dizziness or fainting? Difficulty breathing at night, except in the upright position? Swelling in the ankles or lower extremities (other than due to an injury)? Heart palpitations (rapid or irregular beat of the heart)? Pain in the legs that may cause you to stop walking? Known heart murmur? Are you pregnant or is it likely that you may become pregnant at this time? Have you had surgery or been diagnosed with a disease in the past three months? In the past 12 months, have you been told by a healthcare professional that you have an elevated cholesterol level or abnormal lipid profile, or are you on any medications to control your blood lipids? Do you currently smoke cigarettes, or have you quit within the past six months? Have your father or brother(s) had heart disease prior to the age of 55 or mother or sister(s) had heart disease prior to the age of 65? Do you currently have high blood pressure, or are you taking medication(s) to manage high blood pressure? Within the past 12 months, have you been told by a healthcare professional that you have an elevated fasting blood glucose level? (>100mg/dl) Are you currently under the care of a healthcare professional for blood clots or other circulatory problems? Do you currently experience problems or pain in your bones, joints, muscles that may be aggravated with exercise? Do you currently experience any back and/or neck discomfort or problems? Are you currently under the care of a healthcare professional for any other health/medical problems? None If you have answered yes to any of the questions above please provide additional information here: What, if any, are your main (health) concerns at this time? What are your training goals? What is your occupation: Is your job: Sedentary Moderately active Active How many hours/week do you work? Describe a typical day at work: Describe a typical day off of work: On average, how stressed are you? 1 being lowest & 10 being highest 1 2 3 4 5 6 7 8 9 10 What causes stress in your life? Are you aware of any food or environmental allergies or sensitivities? If so, please list: What types of foods do you normally eat and what time of day do you normally eat them? Breakfast Types & time of day Lunch Types & time of day Dinner Types & time of day Snacks Types & time of day What are your absolute favorite foods? Do you have an aversion to/hate any foods? (If so, please list) History of or current problems with eating disorders, disordered eating or any other food related issues: How many ounces of water do you consume, on average, per day? How many cups of caffeinated beverages do you consume? What, if any, medications/supplements are you currently on? Write them out: Please note: Name of the substance hether it is over-the-counter, herb, prescription, or vitamin, What does self care look like for you? Do you have a morning routine? An evening routine? What do they consist of? How many minutes per day do you spend on self care? 0-10 10-20 20-30 30-60 60+ How do you move your body? Do you have a consistent movement routine? If you had an entire day to yourself with zero obligations, no limitations, how would you spend it? On average, how many hours do you sleep per night? 5 or under 6 7 8 9 10+ Last, but certainly not least, how would your friends describe you? Thank you! HOMEBODY Intake Form
