Health Intake Questionnaire Core Essentials

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Core Essentials intake questionnaire is a vital part of your success. Take the time to answer the questionnaire carefully and add any information regarding your health or physical limitations you may have. Musculoskeletal limitations refer to any muscle strain or joint related issues to the neck, shoulder, knees and back. Any injuries you may have had, previous or present, must be disclosed. Cardiopulmonary or cardiovascular limitations may be hypertension, the usage of heart medication, cholesterol medication and or heart attack. Any cardiopulmonary or cardiovascular issues you may have had in the last 20 years to present must be disclosed. Pre-post pregnancy clients must disclose where they are in regards to their pregnancy and any complications experienced before, during and after pregnancy.

This website has been developed by Core Essentials Inc for information purposes only. It does not provide medical advice, diagnosis, treatment or care. If you have a health problem, medical emergency, or a general health question, you should contact a physician or other qualified health care provider for consultation, diagnosis and/or treatment. Under no circumstances should you attempt self-diagnosis or treatment based on anything you have seen or read on this website. The advice and exercise programs provided by this website are for clients that have no pre-existing physical limitations and are cleared by their physician to exercise without restriction. By submitting this questionnaire you are declaring that you are healthy enough to exercise. Once this form has been submitted your trainer will contact you with the results and possible recommendations.

Health Intake Questionnaire Please complete the following form. Your Personal Trainer will review the information and work with you to produce your personal training program.

Required information.

Optional information.

Contact Information
First Name: MI: Last: Address Line 1: Address Line 2: City: Prov: Postal Code: Country: Email: Phone:
Unit of Measure
Select the unit of measure you wish to use for height and weight entries:
English (inches, lbs)   Metric (cm, Kg)
Personal Information
Sex: Female Male
Pregnant/Nursing: n/a Pregnant Nursing
Height: inches/cm	Age:
Body Frame
If you don't already know your body frame type, try this: place your thumb and middle finger around your wrist. If they overlap, enter "small." If they just touch, enter "medium." If they don't touch, enter "large." Body Frame: Small Medium Large
Activity Level
Check the appropriate activity level that most closely approximates your lifestyle. Examples: Sedentary = working behind a PC. Moderately Active = waiting tables. Active = construction work. Activity level: Sedentary Moderately Active Very Active
Body Weight
Present Weight: lbs/Kg     Desired Weight: lbs/Kg
Desired loss/gain per week: 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.5 3.0 lbs/Kg
Body Weight Charts for Women	Body Weight Charts for Men
Resting Heart Rate Resting Heart Rate:
Please enter your heart rate, measured first thing in the morning before you get out of bed.
Percentage Body Fat Composition Values
Present % Body Fat Content:     Desired % Body Fat Content:
Please enter both values if you want calculations to be based on your body fat content. Body fat calculations will override any value you may have entered for Desired Weight.
Body Fat Chart for Women and Men
Daily Exercise Calorie Expenditure Goals
Exercise Calorie Goal - Monday:	calories
Exercise Calorie Goal - Tuesday:	calories
Exercise Calorie Goal - Wednesday:	calories
Exercise Calorie Goal - Thursday:	calories
Exercise Calorie Goal - Friday:	calories
Exercise Calorie Goal - Saturday:	calories
Exercise Calorie Goal - Sunday:	calories
Exercise Calorie Expenditures Sorted by Activity     Exercise Calorie Expenditures Sorted by Intensity
PCF Ratio Goal
If you aren't sure what your ratio should be, leave them blank... our Registered Dietitians will recommend one for you. Enter your goal for these three variables as a percentage of your total daily calorie intake:
% Protein Calories: % Carbohydrate Calories: % Fat Calories:
(These three percentages must equal 100%. If they don't, we'll enter values for you.)
Personal Goal
This selection is optional. Please select the option that most closely describes your goal: Lose Weight Maintain Weight Gain Weight Increase Athletic Performance
Peak Body Weight
What is the most you ever weighed?:	lbs/Kg
When did you weigh this amount?:	This is my present weight. Within the past three months. Within the past six months. Within the past 12 months. Within the past two years. Within the past five years. More than five years ago.
Medical Conditions
Please select as many as apply:
Anemia   Asthma   Colitis   Diabetes   Gastric Reflux   Hypertension	Hypoglycemia Irritable Bowel Syndrome Heart Disease Hiatal Hernia Liver Disease Other (specify):
Comments and Additional Information
Please enter additional information you feel is important to consider in your personal assessment.