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0437 571 540
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Goals
–
Step
1
of 6
Name
*
Gender
Male
Female
Other
Goal
Obstacles / Previous Issues
Availability
Next
Remind the client that information in ph360 is private unless they decide to accept us as a coach. These questions are required to ensure that its safe for you to exercise.
Pre Exercise Stage 1
Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
*
Yes
No
Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
*
Yes
No
Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
*
Yes
No
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
*
Yes
No
If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
*
Yes
No
Do you have any other conditions that may require special consideration for you to exercise?
*
Yes
No
Please Provide Details
Due the clients answers medical clearance is required before they begin training.
Next
Current Activity Level
Low or Moderate Intensity Training
Selected Value:
0
How Many Minutes Do you Spend Doing Low or Moderate Intensity Exercises?
High Intensity Training
Selected Value:
0
How Many Minutes Do you Spend Doing High Intensity Exercises? High Intensity Exercises counted as double for total exercises time.
Is the client currently exercising more than 150 minutes per week?
*
Yes
No
Other Risk Factors
Is there a Family history of early heart disease ?
*
Yes
No
A family history of heart disease refers to an event that occurs in relatives including parents, grandparents, uncles and/or aunts before the age of 55 years.
Details – Relationship & Age
Do you Smoke on a daily or weekly basis or have you quit in the last 6 months?
*
Yes
No
Have you been told that you have high cholesterol/ blood lipids?
*
Yes
No
If known: Total cholesterol, HDL, LDL, Triglycerides (mmol/L)
Any of the below increases the risk of heart disease: Total cholesterol ≥ 5.2 mmol/L HDL < 1.0 mmol/L LDL ≥ 3.4 mmol/L Triglycerides ≥ 1.7 mmol/L
Are Taking Any Medication for high cholesterol/ blood lipids?
*
Yes
No
Please Provide Details
Are you taking prescribed medications for any condition that we haven't already covered?
*
Yes
No
Please Provide Details of Prescribed Medications
Have you spend any time in hospital in the last 12 months for any reason? ?
*
Yes
No
Please Provide Details of Hospital Stay
Have you given birth in the last 12 month?
*
Yes
No
Do you have any *diagnosed* muscle, bone or joint problems ?
*
Yes
No
Details
Other Notes
I believe that to the best of my knowledge that all information I have provided is correct. (Please Sign in the box below)
Clear Signature
Previous
Next
Squat
Pass
Fail
Single Line Text
Left Leg Balance
Fail
Eyes Open
Eyes Closed
Single Line Text (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Right Leg Balance
Fail
Eyes Open
Eyes Closed
Single Line Text (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Standing Forward Bend
Pass
Fail
Single Line Text (copy)
Standing Extension
Pass
Fail
Single Line Text (copy) (copy)
Shoulder Flexion
Pass
Fail
Single Line Text (copy) (copy) (copy)
Shoulder Abduction
Pass
Fail
Single Line Text (copy) (copy) (copy) (copy)
Empty Can
Pass
Fail
Single Line Text (copy) (copy) (copy) (copy) (copy)
L Hand Behind Back
Pass
Fail
Single Line Text (copy) (copy) (copy) (copy) (copy) (copy)
R Hand Behind Back
Pass
Fail
Single Line Text (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Seated Forward Bend
Pass
Fail
Single Line Text (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Elbows to Sky (Seated)
Pass
Fail
Single Line Text (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Rotation L=R (Seated)
Pass
Fail
Single Line Text (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Side Bend L=R
Pass
Fail
Single Line Text (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Next
Health Type
Activator
Connector
Gurdian
Diplomat
Sensor
Crusader
Number
Chest Expansion
Fail (Less than 3 cm)
Pass (Greater than 3cm)
Next
Classes to Attend
Restrictions
ie. No Jumping movements until clearance from physio
Note & Other Interventions
Ie. Needs some breath work help, follow up in 3 weeks about schedule
Submit