Health Assessment

First Name *

Last Name *

Date of Birth *

Date *

Cell Phone *

Email *

Zoom Handle (Zoom Contact Info)

Male/Female *

Male

Female

Emergency Contact Information

First Name *

Last Name *

Relationship *

Cell Phone *

Physician's Name *

Physician's Phone Number *

The following questionnaire is not intended for diagnosis but rather to fully understand your health history as well as to help identify your health, fitness and nutrition goals.

There are no incorrect answers, it is only important that you answer honestly and completely.

We look forward to working with you!

Sozo Health and Fitness

Activity

1. Have you ever done resistance/strength training before? *

Yes

No

2. What type of exercise do you prefer? *

Other Form/s of Exercise (Explain) (Type "None" if there are no other forms.) *

3. Do you currently have a fitness routine? (If so please explain below.) *

Yes

No

Type of Exercise

Duration of Session

Time during the week

Type of Exercise

Duration of Session

Time during the week

4. What do you enjoy most about exercise?

5. What do you enjoy least about exercise?

Rest

1. How many hours sleep do you typically get on a weeknight?

2. How many hours sleep do you typically get on a weekend night?

3. Do you experience points during your day when you are tired?

Yes

No

If yes, when?

Health History

1. Do you have high blood pressure? (Healthy is considered to be 120/80 mmHg, High BP is 140-159/90-99 mmHg.) *

Yes

No

If yes, please explain. (If "No", type "None".) *

2. Do you have high cholesterol levels? (Healthy is considered to be less than 200mg/dL, borderline high is 200-239 mg/dL, high is 240 mg/dL and above.) *

Yes

No

If yes, please explain. (If "No", type "None".) *

3. Do you experience pain in any of these areas? *

Other (Please explain.) (Type "None" if "None" was selected.) *

If you selected any of the options for question 3 please explain. (Type "None" if "None" was selected.) *

4. Do you smoke? *

Yes

No

If so, how many cigarettes do you smoke per day? (If "No", type "None".) *

5. Are you taking any medications or supplements? *

Yes

No

If you answered yes, please list any medications and/or supplements here. (If "No", type "None".) *

6. Please list any other general health/wellness issues here. (If you do not, type "None".) *

Nutrition

1. Do you have any food allergies? *

Yes

No

If you answered yes: What are the foods? What is your reaction to these foods? (If "No", type "None".) *

2. What times do you regularly eat within a day and what do you eat? (Example: 7am: Omelet w/ Veggies, 10am: Fruit w/ Yogurt, etc...) Enter Wake up time here.

Enter "wake up time" here.

Time

Meal

Time

Meal

Time

Meal

Time

Meal

Time

Meal

3. Do you experience points during your day of significant hunger? *

Yes

No

If yes, when?

4. Do you crave more salty or sweet snacks? None? *

What types of choices do you typically make to satisfy these cravings?

5. Do you drink coffee? *

Yes

No

If you drink coffee, do you drink it more for: [Taste, Caffeine, or Both]?

6. At what time of day are you most likely to drink coffee and how many cups?

Time of Day (i.e. 7am, 1pm, 10pm)

Number of Cups (1 Cup = 8 Ounces)

Caffeinated, Decaffeinated, Both

7. Do you drink soda pop? *

Yes

No

If you drink soda pop, do you drink it more for: [Taste, Caffeine, or Both]?

8. At what time of day are you most likely to drink soda pop and how much?

Time of Day (i.e. 7am, 1pm, 10pm)

Number of Cans/Bottles (1 Can = 12 Ounces)

Regular or Sugar-Free or Both

9. Do you drink alcoholic beverages? *

Yes

No

10. What time of day are you most likely to drink, what type of alcohol and how much?

Time of Day (i.e. 7am, 1pm, 10pm)

Number of Cans/Glasses/Bottles (1 Glass = 5 Ounces)(1 Can/Bottle = 16 ounces)

Type of Beverage (i.e. Wine, Beer, Vodka)

Goals

What are your primary goals or desires for improving your health and fitness? Please be as specific as possible including a date upon which you would like to see your goals met.

I agree that all information stated in this document is accurate and complete.

I understand that a facsimile, electronic, pdf or DocuSigned signature will have the same force and effect as an original.

Client's Signature *

Print Name *

Date *

If under the age of 18, Signature of Parent or Guardian (If not, type N/A) *

Print Name (If not, type N/A) *

Date *