Health and Fitness Evaluation

Health and Fitness Evaluation

This form is used to evaluate your health and assist in planning your workouts. All information will be kept confidential. Fill in, circle, and/or check the appropriate words or boxes.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Cell:*
Phone (other)*
Email*
Date Of Birth mm/dd/yyyy*
MM slash DD slash YYYY
Age:*
Height:*
Occupation:*
Work Hours per week:*
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
Past and Present History
Do you have high blood pressure?*
- Yes
- No
Do you have high cholesterol?*
- Yes
- No
If Yes, please list medications for high blood pressure or cholesterol
If Yes, List any exercise restrictions with these medications?
Do you have now, or in the past, any indications of heart disease?*
- Heart Attack
- Heart Valve Disorder
- Angina
- Arrhythmia (irregular heartbeat)
- Heart Murmur
- Peripheral Vascular Disease (PVD or PAD)
- Diabetes -Type 1
- Diabetes -Type 2
- Kidney disease
- Stroke
- TIA
- Other
- None
Have you undergone any of the following heart procedures/surgery?*
- Angioplasty
- By-pass Surgery
- Stent placement
- Heart Catheterization
- Heart Transplant
- Pacemaker Implanted
- Implanted Cardiac Defibrillator
- Other
- None of the above
Other indications of heart disease?
Signs and symptoms of heart attack check: Have you recently experienced the following?*
- Pain, discomfort in the chest, neck, jaw at rest or upon exertion
- Shortness of breath at rest or with mild exertion
- Dizziness or loss of consciousness during or shortly after exercise
- Shortness of breath occurring at rest or 2-5 hours after the onset of sleep
- Swelling in both ankles that is most evident at night or swelling in a limb
- An unpleasant awareness of forceful or rapid heartbeats
- Pain in the legs or elsewhere while walking
- Severe pain in legs or elsewhere when walking upstairs or uphill
- Unusual fatigue or shortness of breath with usual activities
- None
Do you have any family history of heart disease?*
- Mom
- Dad
- Siblings
- No family heart disease known
Do you smoke?*
- Yes
- No
Did you quit smoking within the last 6 months?*
- Yes
- No
Do you have a pulmonary disease?*
- Yes
- No
Do you have any of the following?*
- COPD
- Asthma
- Chronic bronchitis
- None of the above
Any other pulmonary disease?
Do you have now, or in the past, any other illnesses? diseases?*
- Yes
- No
List any other Illness /Disease/ Limitations
Illness/Disease/ Limitation Past treatment Current treatment
Do you have now, or in the past, any injuries?*
Injuries Past treatment Current treatment No | None
Are you currently or recently experiencing any pain in your body?*
- Yes
- No
Describe the body parts in pain here*
Pain location Past treatment Current treatment None
Have you had any surgeries not listed above?*
Surgery Type Year Details No Surgery
Please list any other medical conditions, or reasons not listed above that may affect your ability to exercise:
Are you pregnant or planning on becoming pregnant in the near future?*
- Yes
- No
If pregnant, please state due date:
Medications Outside of blood pressure and cholesterol medications, please list all additional medications here:*
Medications Exercise Restrictions Details None
Current Physical Condition; Over the last 3 months have you regularly participated in physical activity for at least 30 minutes three days/week at:*
No Yes, moderate (brisk walking intensity) Yes, vigorous-intensity (jogging intensity)
What physical activities structured or unstructured do you do?*
Activity (gym/yoga/walk/garden etc) Per week Duration
Past exercise history (answer in box below)*
What other types of exercise have you done in the past? (e.g. sports)
Have you weight trained before? (answer in box below)*
No Yes, details please
Have you trained with a personal trainer before? (answer in box below)*
No Yes, details please
Do you follow any specific eating program? (answer in box below)*
No Yes, details please
What are your personal health and fitness goals? (Results in; 6 months | a year?
Please rate the following: 1 you disagree to 10 strongly agree
Excellent current state of health/well being*
My body is fit and strong*
I regularly exercise*
I enjoy the benefits of exercise*
I have healthy current nutritional habits?*
My eating habits leave me generally satiated and healthy*
My stress is well managed*
I am happy with my body shape and size*
I generally sleep well*
My digestion is regular and healthy*
I have enough energy to get through the day*
I move/stand instead of sit most of the day*
I have a healthy level of stress in my day*
I drink an adequate amount of water per day*
(½ oz for each LB of my body weight)
I am able to achieve my activities of daily living with ease and without pain*
Consent*
I hereby declare that the above answers are true. I also declare that I have no medical history or injuries, which I have not made known to the trainer. I will inform the trainer of any changes to my medical conditions and or physical injuries as soon as they occur. I am under no obligation to participate in any of the exercises set by the trainer Lila Ristevska (Coach Lil). Should I accept to take part in any exercises, I do this wholly under my own responsibility and with the knowledge that exercises may have a risk of injury. I do not hold Lila Ristevska (Coach Lil) responsible or liable for any injury or illness. I have read and understand and agree to all of the conditions set out in this form. I agree to cancel/reschedule not less than 24 hours before any personal training time set or I am required to pay in full for that session.
Consent of parent/guardian of dependent under 18 years of age
I hereby allow my child to participate in training with Coach Lil (Lila Ristevska) or other trainer. I have read and understand and accept all of the conditions above.
Please sign here*
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Voted Best Fitness Trainer in Palm Beach!

No Intimidation, Confusion or Ego

(561) 713-6403

5 Stars - Based on 7 User Reviews

James BallardLil is a truly awesome trainer!
Lil is a truly awesome trainer! I truly believe that if Lil can't do what you need done in the personal training niche then it can't be done. My life is better for knowing her!.
Gyrotonic SatNamGreat results and great teacher!!!
Lila has being part of our team for over 10 years. Her Classes are absolutely amazing. Great results and great teacher!!!
anna abbotthttps://www.google.com/maps/contrib/109312395689709261939/photos/@26.7041998,-80.0408086,17z/data=!4m3!8m2!3m1!1e1?hl=en-US
Jorge SanabriaLila helped me with literally every aspect of my body shes great
LIla is one of the best sweetest people ive ever met. She over qualified to do these things. Lila helped me with literally every aspect of my body shes great and she can match the best out there!
Jan SteinLila is the mastermind of personal training!
Coach Lil is an excellent trainer; hands- down, she's better than almost everyone in the U.S. and globe because Lil's an Australian National althlete? ??????????an ELITE WRESTLER athlete?herself. THERE'S A HUGE DIFFERENCE BETWEEN COACH LIL AND EVERYONE. Lil has earned coach and nutrition certifications via highly credible educator professionals. Mainly Lil's patient with, and focused on her geriatric clients such as myself (who's age 69.) Call Lil today~~ arrange NOW for starting YOUR TRAINING PROGRAM and to feel a much-improved lifebody! Sincerely, Jan Stein/Palm Beach, FL
Carole Manninghttps://www.google.com/maps/contrib/108771479783336889109/photos/@26.7041998,-80.0408086,17z/data=!4m3!8m2!3m1!1e1?hl=en-US
Darlene BallardOpened my eyes to see that exercise without pain was even possible
Thanks, Lil for showing me the OzzyBall System, and opened my eyes to see that exercise without pain was even possible. I am so thankful for your worldly experience as an Olympian with injury prevention and injury strengthening exercises, that can guide me back to being the strong person I used to be.

Health and Fitness Evaluation

Health and Fitness Evaluation

Past and Present History

Please rate the following: 1 you disagree to 10 strongly agree

Voted Best Fitness Trainer in Palm Beach!

No Intimidation, Confusion or Ego

Mon- 8:00 am–8:00 pm

Tue – 8:00 am–8:00 pm

Wed- 8:00 am–8:00 pm

Thu- 8:00 am–8:00 pm

Fri- 8:00 am–8:00 pm

Sat- 9:00am – 12:00pm

Sun- Closed

No	Yes, moderate (brisk walking intensity)	Yes, vigorous-intensity (jogging intensity)

What other types of exercise have you done in the past? (e.g. sports)

Illness/Disease/ Limitation	Past treatment	Current treatment

Injuries	Past treatment	Current treatment	No \| None

Pain location	Past treatment	Current treatment	None

Surgery Type	Year	Details	No Surgery