Online Fitness & Wellness Assessment (Zoom Intake Form)
Purpose: This assessment helps identify health risks, exercise readiness, lifestyle habits, and nutrition patterns before beginning a beginner-level home fitness program using bodyweight exercises, yoga, mobility work, and healthy nutrition education.
CLIENT INFORMATION
Full Name: ______________________________________
Date: ____________________
Age: __________
Gender: __________________
Height: __________
Current Weight: __________
Phone: __________________
Email: __________________
Emergency Contact Name: __________________
Emergency Contact Phone: __________________
MEDICAL & SAFETY SCREENING
Have you ever been diagnosed with any of the following?
☐ Heart Disease
☐ High Blood Pressure
☐ High Cholesterol
☐ Stroke or TIA
☐ Diabetes (Type 1 or Type 2)
☐ Asthma or Breathing Problems
☐ COPD
☐ Kidney Disease
☐ Liver Disease
☐ Thyroid Disorder
☐ Arthritis
☐ Osteoporosis
☐ Cancer
☐ Autoimmune Disease
☐ Neurological Disorder
☐ None of the Above
If yes, please explain:
Are you currently taking any medications?
☐ Yes
☐ No
If yes, list medications:
Have you had any surgeries, injuries, or hospitalizations in the past 5 years?
☐ Yes
☐ No
If yes, explain:
Do you currently experience any of the following?
☐ Chest Pain
☐ Dizziness
☐ Fainting
☐ Shortness of Breath
☐ Heart Palpitations
☐ Swelling in Legs or Feet
☐ Severe Fatigue
☐ Frequent Headaches
☐ Balance Issues
☐ None
Do you have pain or limitations in any of the following?
☐ Neck
☐ Shoulders
☐ Upper Back
☐ Lower Back
☐ Hips
☐ Knees
☐ Ankles
☐ Wrists
☐ Other: __________________
Has a doctor ever told you not to exercise?
☐ Yes
☐ No
EXERCISE READINESS
Current Activity Level
☐ Completely Sedentary
☐ Light Activity (1-2 days/week)
☐ Moderate Activity (3-4 days/week)
☐ Active (5+ days/week)
How long has it been since you exercised consistently?
☐ Never
☐ Less than 6 Months
☐ 6-12 Months
☐ 1-3 Years
☐ More than 3 Years
What forms of exercise have you enjoyed in the past?
☐ Walking
☐ Yoga
☐ Stretching
☐ Bodyweight Exercise
☐ Swimming
☐ Cycling
☐ Sports
☐ Other: __________________
Can you comfortably:
Walk for 15 minutes? ☐ Yes ☐ No
Stand for 30 minutes? ☐ Yes ☐ No
Sit on the floor and get back up? ☐ Yes ☐ No
Go up one flight of stairs? ☐ Yes ☐ No
NUTRITION & LIFESTYLE
How many meals do you typically eat per day?
☐ 1
☐ 2
☐ 3
☐ 4+
How often do you eat fast food?
☐ Never
☐ 1-2 Times/Week
☐ 3-5 Times/Week
☐ Daily
How many servings of vegetables do you eat daily?
☐ 0
☐ 1-2
☐ 3-4
☐ 5+
How much water do you drink daily?
☐ Less than 32 oz
☐ 32-64 oz
☐ 65-100 oz
☐ 100+ oz
Alcohol Consumption
☐ None
☐ Occasionally
☐ Weekly
☐ Daily
Tobacco or Nicotine Use
☐ Yes
☐ No
Average Sleep Per Night
☐ Less than 5 Hours
☐ 5-6 Hours
☐ 7-8 Hours
☐ 8+ Hours
Stress Level (1-10)
1 2 3 4 5 6 7 8 9 10
GOALS & MOTIVATION
What are your top 3 goals?
☐ Lose Weight
☐ Build Healthy Habits
☐ Increase Energy
☐ Improve Mobility
☐ Improve Flexibility
☐ Reduce Stress
☐ Build Strength
☐ Improve Balance
☐ Improve Overall Health
☐ Other: __________________
What has prevented you from reaching your goals previously?
On a scale of 1-10, how committed are you to making lifestyle changes?
1 2 3 4 5 6 7 8 9 10
What would success look like for you in the next 90 days?
COACH OBSERVATION SECTION (ZOOM)
Visual Posture Assessment
☐ Forward Head
☐ Rounded Shoulders
☐ Excessive Arching
☐ Flat Back
☐ Balance Concerns
☐ No Significant Issues Observed
Basic Movement Screening
☐ Sit-to-Stand
☐ Assisted Squat
☐ Arm Reach Overhead
☐ Single-Leg Balance
☐ Forward Fold
☐ March in Place
Notes
INFORMED CONSENT
I understand that participation in exercise involves some risk. I affirm that the information provided is accurate to the best of my knowledge. I agree to stop exercise immediately and notify my coach if I experience chest pain, dizziness, severe shortness of breath, or any unusual symptoms.
Client Signature: _______________________________
Date: __________________
Coach Signature: _______________________________
Date: __________________
Red-Flag Referral Checklist (Do Not Begin Exercise Until Cleared by Physician)
☐ Unexplained chest pain
☐ Recent heart attack or stroke
☐ Uncontrolled blood pressure
☐ Severe shortness of breath
☐ Unexplained fainting
☐ Major recent surgery
☐ Uncontrolled diabetes
☐ Significant balance/fall risk
☐ Any physician-directed exercise restriction
If any box above is checked, obtain medical clearance before beginning a fitness program.