Health & Goals Questionnaire Step 1 of 7 14% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM DD YYYY Age*Height*Weight*Phone*Email* Assistant's PhoneAssistant's Email Emergency Contact* First Last Relationship*Emergency Contact Phone*How did you hear about Luisa Noelle?*Do you have a gym in your home or building?*YesNoIf yes, please list the equipment that you have access to: All are requiredHas a physician ever diagnosed you as having high blood pressure {>160/90} or are you currently on any high blood pressure medication?*YesNoIs your cholesterol higher than 240 mg/DL?*YesNoPlease enter your cholesterol*Please enter a number less than or equal to 500.mg/DLDo you smoke?*YesNoIf so, when did you start?*How many cigarettes per day?*Please enter a number from 0 to 100.Do you consume alcohol?*YesNoIf so, what type?*How many beverages per week?*Please enter a number from 0 to 100.Do you have diabetes?*YesNoHas anyone in your immediate family suffered from coronary or atherosclerotic disease prior to age 55?*YesNoAre you, or do you think you may be pregnant?*YesNo Has your doctor ever said you have heart trouble, coronary heart disease or high blood pressure?*YesNoDo you frequently experience pain or discomfort in the heart or heart area?*YesNoDo you suffer from shortness of breath at rest or upon mild exertion?*YesNoDo you suffer from dizziness or fainting?*YesNoDo you have difficulty breathing?*YesNoDo you suffer from swollen ankles due to circulation problems or metabolic condition?*YesNoDo you experience pain i your limbs when exercising or moving?*YesNo All medical history requiredAre you on any medications that induce ligh headedness or dizziness?*YesNoList any medications you are taking that could potentially affect your ability to exercise (medications that make you lightheaded or dizzy and the condition prescribed):*Do you have any allergies?*YesNoIf so, what are they?*Do you consider your life stressful?*YesNoIf so, how stressful? (1-10 and 10 being most stressful)*Please enter a number from 1 to 10.Do you practice stress management?*YesNoIf so, what methods do you use?*Do you have any current or past injuries, aches or pains that we should be taken into consideratino when designing your program?*YesNoIf so, please explain* Do you currently exercise?*YesNoHow many times per week do you currently exercise?*Please enter a number from 0 to 100.For how long? (minutes/day)*Please enter a number from 0 to 1000.If you exercise, please provide Aerobic Training details below (type of activity, pace, time, frequency)*If you exercise, please provide Strength Training details below (type of exercise, amount of resistance, number of sets and repetitions performed)*How would you rate your eating habits?*1 (significant room for improvement)2 (some room for improvement)3 (I’m a super star!)How willing are you to make the needed tweaks to your eating habits to support our work for your goals?*1(it will be very hard for me)2 (A challenge I am ready to work on)3 (I’m all in!) All are requiredWhat is the main reason that compelled you to start this training?*How do you picture yourself 3 months from now physically?*How do you picture yourself 3 months from now emotionally?*How do you picture yourself one year from now physically?*How do you picture yourself one year from now emotionally?*What are the primary goals you would like to reach with your exercise program (genral strength, fat loss, flexibility, sports training, improve a specific body part, sport/skill, low back strength, etc. Please be as specific as possible):*How ready are you to do what it takes to commit to these goals?*1(it will be very hard for me)2 (A challenge I am ready to work on)3 (I’m all in)What do you foresee as your biggest challenge?*If you had to give 3 keywords you need to feel in order to be successful, what would they be?*What intensity do you prefer for your workouts?*LowModerate IntensityIntenseVery IntenseYour ideal & amazingly fun fitness-training program would include...(i.e. swimming, boxing, yoga, strength training):* Client Name:* First Last Do you certify that all the information provided is true?* Yes Date* Date Format: MM slash DD slash YYYY CaptchaNameThis field is for validation purposes and should be left unchanged.