Back in Action Onboarding Form

BACKGROUND & HEALTH

First name

Last name

2. Family history of heart disease (e.g. stroke, heart attack)?

3. Do you suffer from (tick all that apply)

Asthma

Diabetes (including pre-diabetes)

Epilepsy

Osteoporosis or osteopenia

4. Do you have (tick all that apply)

Back or neck pain

Pain or restricted movement in any other joints (hip, knee, ankle, shoulder)

Diagnosed hypermobility

5. If yes, please provide further detail

6. Do you smoke cigarettes (or have quit within the last 6 months)?

Yes

7. What is your weekly/monthly alcohol intake?

8. Please provide information on body composition

9. Do you have high blood pressure?

Yes (controlled with medication)

Yes (not controlled with medication)

10. Are you currently taking prescribed medication(s) for any condition(s)? Other than those already mentioned.

Yes

11. If yes, what are the medical conditions?

12. Have you spent time in hospital for any condition/illness/injury during the last 12 months?

Yes

13. Are you pregnant, or have given birth within the last 12 months?

Yes

14. Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been advised could be made worse by participating in exercise?

Yes

15. If yes, please provide details

16. Are there any other conditions or information that could be relevant? If yes please provide details

SPORT, ACTIVITY, LIFESTYLE, INJURY & PAIN

17. Please list all the types of activity (sports/exercise) you do regularly

LIFESTYLE AND HABITS

INJURY AND PAIN - If you have pain and/or injury: If you have no pain or injury go to question 32.

22. Where is the pain, what does it feel like, and how long have you had it?

26. What movements trigger or relieve it?

27. How does it affect you (daily function, mood, work, sport)?

28. What have you tried to resolve it?

29. Are you seeing any specialists i.e. doctor, osteopath, chiropractor, physio etc. for your pain or any musculoskeletal issues?

31. Are you happy for me to contact the practitioner so that we can align our work so that we can get you the best outcome?

Yes

STRESSORS & LIFESTYLE FACTORS THAT CAN CONTRIBUTE TO PAIN

Rate yourself on each area below.

HEALTHY BEHAVIOURS & SUPPORT THAT CAN BUILD RESILIENCE AND REDUCE PAIN

Score where you are right now

GOALS & CHALLENGES

GOALS & MOTIVATION

40. Describe what your final goal or outcome is.

41. Why are these goals important to you? Understanding “why” helps me tailor your coaching to help you get you where you want to be.

CHALLENGES & BARRIERS

If you selected other, please provide detail

43. Have you tried other programmes or exercise routines in the past? What worked / didn’t work?

FINAL DETAILS (I PROMISE!!)

47. What time can you realistically commit to in a week for this programme? Are there any days/times you prefer to train, or absolutely cannot train?

48. Is there anything else you want to share, or feel I should know to make your programme as effective and enjoyable as possible?