Health History and Lifestyle Consultation Form

Fitness & Health Information

Are you, or do you think you are, pregnant?
Yesno

Are you planning on becoming pregnant?
YesNo

If yes, approximately when:

Have you ever participated in any type of strength-training program?
YesNo

If yes, what type?

Have you ever participated in Yoga, Qigong, meditation or Tai Chi?
YesNo

Have you ever participated in any form of breath-work? YesNo

Have you ever participated in aromatherapy, music therapy or homeopathy?
Yesno

Are you interested in additional ways to reach your goals beyond ZoeFit Sessions,
examples: educational material, supplements, breathing techniques?
YesNo

Exercise, sports, or recreational activities? (Please list.)

Past:

Present:

Are there any physical recreational activities or sports which you would like to
participate in once you have achieved a greater level of physical condition?

How long is your work day?

Is your job more physically or mentally
demanding?

Do you regularly travel out of town for work and/or pleasure : If yes, how
much

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16%

Are you taking any over-the-counter meds and/or herbs more than once a week?
YesNo
If yes, please list:

Have you had any broken bones or operations in the last five years?
YesNo
If yes, please explain:

Have you had any areas of weakness or muscle tension?
YesNo
If yes, please explain:

Do you have, or have you had, any of the following

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33%

Any other injury or condition?

If yes to any of the above, has your doctor cleared you for your exercise program?
YesNo

Are you on any restrictions from your Physician?
YesNo

If yes, please If describe:

Are you currently under a physicians care for any reason?
YesNo

Describe:

Is there any additional information that your Instructor needs to know in order to keep
your program as safe and productive as possible?

Do you have any concerns about participating in our exercise program?

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50%

Life Stress Survey

Instructions:

Review the last year and the Events that happened to you. Beside each event, indicate
the Number of Times it happened to you during the past 12 months only.

Death of a spouse

100 * =

Divorce:

73 * =

Marital separation:

65 * =

Jail term

63 * =

Death of close family member:

63 * =

Personal injury or illness:

53 * =

Marriage:

50 * =

Loss of employment:

47 * =

Marital reconciliation:

45 * =

Challenges with children:

45 * =

Retirement:

45 * =

Change in family member’s health:

44 * =

Change in financial status:

44 * =

Pregnancy:

44 * =

Business readjustment:

39 * =

Death of close friend

37 * =

Change to different line of work:

36 * =

Change in number of marital arguments

35 * =

Mortgage or loan over $20,000:

31 * =

Foreclosure of mortgage or loan:

30 * =

Change in work responsibilities

29 * =

Son or daughter leaving home

29 * =

Trouble with in-laws:

29 * =

Outstanding personal achievement:

28 * =

Spouse begins or stops work:

26 * =

Begin or End School:

26 * =

Change in living conditions:

25 * =

Revision of personal habits:

24 * =

Trouble with boss:

23 * =

Change in working hours or conditions:

20 * =

Change in residence:

20 * =

Change in school:

20 * =

Change in recreational habits:

19 * =

Change in church/religious activities:

18 * =

Change in social activities:

18 * =

Mortgage or loan under $20,000:

17 * =

Change in sleeping habits:

16 * =

Change in number of family gatherings:

15 * =

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15 * =

Vacations:

13 * =

Holiday season:

12 * =

Sleep

What time do get into bed? How many minutes until you fall asleep?

What time do you wake up?

How many hours do you tend to sleep per night?

How many times do you wake up per night?

Caffeine, Meals & Water

Do you drink any type of caffeine? What time/s of day? What is the
source(coffee,tea,etc.)?

What time do you have your 1st meal/snack? What do you have your last meal/snack?

How many meals & snacks do you consume per day?

How many ounces of water do you drink per day?

Alcohol

Do you drink any type of alcohol? How many days per week?

What type of alcohol? What do you tend to have your last drink?

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83%

Client Release Form

I,, have enrolled in a program of physical activity, including but not limited to, body conditioning machinery used during the exercise session offered by ZoeFit . I affirm that I am in good physical condition and do not suffer from any disability that would contribute to injury.

Liability Waiver

Participating in an exercise program naturally involves risk of injury to you, whether you or someone else causes it. For and in consideration of the design of an exercise program for the above named client by ZoeFit, the client agrees:

I certify that my answers to the statements listed above are true and complete to the best of my knowledge, and that any exercise program shall be undertaken by the client at his/her sole risk, and release my instructor from all claims, injuries, damages, action or causes of action, and in consideration of my participation in any ZoeFit workshops, workout sessions and/or classes, I release ZoeFit from any claims, demands, and causes of action arising from my articipation in an exercise program and from all acts of active or passive negligence on the part of the company, facility, its owner, agents or employees.

I fully understand that I may injure myself as a result of my participation and I release ZoeFit from any liability now or in the future, including but not limited to, heart attacks, muscle strains, muscle pulls or tears, shin splints, heat exhaustion, knee or foot injuries, back injuries and any other illness, soreness or injury caused, occurring during or after my articipation at ZoeFit.

I affirm that I have read, understood and agree to the above:

Signed:

Date:

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