Total Wellness Coaching
Where to Find Me
Book a Session
About Us
Fitness Blog
Contact
Total Wellness Coaching
Where to Find Me
Book a Session
About Us
Fitness Blog
Get in shape for the Mile High City & beyond
Contact
Name
*
First Name
Last Name
Date of Birth
*
Height
Current Weight
*
Weight 6 months and 1 year ago
Ideal Weight
Goals
*
Number of days of exercise per week (on average the past 30 days)
*
What is currently included in your regular exercise routine? (Be as specific and detailed as possible)
*
Did you play any sports in high school or college? If so, what sports?
At work, do you spend more than 25% of the time (check all that apply):
*
Sitting at a desk
Standing
Lifting heavy objects
Walking
Driving
In the past 6 months, have you been diagnosed with
*
High Blood Pressure
Low Blood Pressure
Arthritis
High Cholesterol
Diabetes
Coronary Heart Disease or Coronary Artery Disease
None of the above
Are you currently taking any medication? (If so, please list medications)
*
In the past 6 months have you had any surgeries? If yes, please describe surgery/injury and how long ago it occurred.
*
After walking up a flight of stairs, do you feel out of breath?
*
Yes
No
Do you frequently suffer pain in your chest or heart during or immediately following moderate or intense physical activity?
*
Yes
No
How long have you lived in Colorado?
*
Please list any other muscular or joint problems are any other reason that might limit, restrict, or cause significant pain while exercising or doing physical activity
*
Thank you!
