Health Management Intake Form

Name

Age

Date of birth

Address

Address 2

City/Town

State

ZIP

Phone Number (day)

Phone Number (evening)

Email Address

Primary Care Physician

Please list any chronic health conditions that you currently have

e.g. heart disease, diabetes, hypertension, arthritis, cancer, etc.

Please list any past or present injuries and/or surgeries that may affect your ability to exercise

Please indicate any medications that you are currently taking

Have you had any recent hospitalization(s)? (include dates)

Have you had any falls or lost consciousness in the last 6 months? (include dates)

Additional physical or mental health information

Your occupation

Does your occupation involve regular physical activity?

Who do you live with?

Do they support your decision to improve your health?

If you are you currently engaging in regular physical activity please indicate the type, frequency and duration of your exercise

Do you currently smoke, drink alcohol or consume any other substances that may affect your health?

What areas of your health would you like to see improvements in?

What areas of your health would you like to see improvements in?
What areas of your health would you like to see improvements in?
What areas of your health would you like to see improvements in?
What areas of your health would you like to see improvements in?

Which session times would work best for you to attend?

Mornings (6:00am – noon)

Afternoons (noon – 5:00pm)

Evenings (5:00pm – 9:00pm)

Questions about how AL!VE can help you reach your goals? Get in touch.