Part 1: Client Data
*  required to complete (thank you)
Today's Date:
*
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Your Name:
Address:
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City:
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State:
Zip:
Home Phone:
Day Phone:
Mobile:
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Email Address:
Which is the best way to reach you?
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Age:
Gender:
Male
Female
Doctor's name:
Doctor's Phone:
Emergency Contact
Phone number:
Relationship:
How did you find out about Pates Running & Racing?
*
Please explain:
Other-than-Athletic Life (optional):
Occupation:
Hours worked weekly:
Married:
Yes:
No:
Spouse's name:
Children:
Yes:
No:
Ages:
Part 2: Health History
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On this questionnaire, a number of questions regarding your physical health are to be answered. Please  answer
every question as accurately as possible so that a correct assessment can be made. Any questions answered
Yes will be discussed during our introductory phone call. Your responses will be treated in a confidential manner.
No:
Yes:
1. Have you or anyone in your family had coronary artery disease?


2. Do you ever have chest, shoulder, neck, or arm pains after exercises?


3. Have you ever fainted, felt dizzy, or unusually winded after exercise?


4. Has a doctor said that your blood pressure is too high or uncontrolled?


5. Has a doctor ever said you have a heart condition, a heart murmur, or a heart attack
and you should only do physical exercise recommended by your doctor?


6. Are you diabetic, have a thyroid condition, or any chronic condition?


7. Are you using any medications?


8. Is your cholesterol level high? What’s your cholesterol count?


9. Have you ever had a complete physical exam including stress test on a treadmill or
ergometer?


10. Do you have any condition that a doctor says may limit your exercise?


11. Have you ever smoked? If yes, when did you quit?


12. Have you ever had a joint or back disorder or any current injury?


13. Have you had surgery in the last 12 months?


14. Are you now, or have you been pregnant in the last three months?
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
No:
Yes:
No:
Yes:
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
No:
Yes:
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Part 3: Exercise History and Interests
On this questionnaire, we present a number of questions regarding your
history of exercise and your personal preferences. This information will help me
create a personalized workout plan for you.
On average, how many times do you exercise per week?


On average, how long do you exercise per session?


On a scale from 1 to 5, how intense is your typical workout?

Very Easy 1                 2                 3                 4                5  Very Intense

For each activity below in which you participate, indicate your
typical exercise in minutes:

Weight Training:

Skiing/Snowboarding:

Running/Jogging:

Duathlon/Triathlon:

Walking:

Aerobics Classes:

Yoga/Martial Arts:

Stair Climbing:

Swimming:

Bicycle/Spinning:

Racquet Sports:

Motocross:

Other:


Activity Preferences and Interests
(please explain)
Part 4: Fitness-Related Goals
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This questionnaire will help us to understand your personal fitness goals. It is also a "contract" in
which we ask you to make a commitment to three concrete steps towards fitness and health. It is a
personal contract that you make with yourself and with others concerned with your health. Should
you have any questions, feel free to ask. Your responses will be treated in a confidential manner.
Please indicate your personal health and fitness-related goals:
Lose Weight


Feel Better


Improve Flexibility


Lower My Cholesterol


Reduce Back Pain


Aerobic Fitness


Reduce Stress
Stop Smoking


Look Better


Injury Rehab


Sports Specific


Muscular Strength


Gain Muscle Mass


Improve Diet
Please tell us more about your exercise
goals:



What is your exercise history?



What health improvements do you need?



What other health improvements do you want?



What are your activity preferences?



What barriers to success do you anticipate?



How will you know you are succeeding?



What is your motivation level?



What is your confidence level? low? medium?
high? Please explain?


How much time will you be able to commit to
your fitness? days per week;  minutes per day
By checking the box below, You have read and agree to Pates Running & Racing/The
Training Effect's
Waiver and Release Agreement Form, which constitutes "a writing
signed by You" under any applicable law or regulation.
I agree to terms of the Waiver and Release Agreement Form
Parent auhorization for minor to participate in Pates Running
& Racing and/or The Training Effect Programs.
Thank you for taking the time to complete this questionnaire! Please note that all the information you provide is
confidential and protected and we will never sell, barter, rent, or give out any contact information to anyone. We keep all
information to ourselves.  I respect your privacy and do not share your information with anyone, no one, nada, zilch!
Intake/Assessment Questionnaire
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Pates Running and Racing
TRAIN with CONFIDENCE, RUN INJURY-FREE and RACE FASTER!
PR²
Team
2018