Heart Health Coaching Registration — Rise Endurance LLC ®

Heart Health Coaching Registration Form

First Name

Last Name

Address

Address Line 1

City

State

Zip Code

Country

Phone Number

Date of Birth

Age

Gender

Male

Female

Marital status

Single

Married

Divorced

Do you have children?

Yes

Occupation

Hours per week that you work

How did you hear about us?

Please explain your cardiac issues & concerns

Have you had a recent check-up from your doctor and have you been given the OK to participate in exercise? (If you have not had a recent check up, please schedule one with your doctor and talk to your coach)

Yes

Have you participated in a cardiac rehabilitation program?

Yes

Please explain any heart rate or exercise restrictions your doctor has given you

Height

Weight

What is your resting pulse (if known)?

When was your last blood work testing done?

Are you currently recoverying from any injury, illness, or surgery?

Yes

If yes, please explain

Do you have any other medical conditions or chronic injuries that may flare up & should be taken into consideration in developing you exercise plan?

List any regularly used over the counter or prescription medications

List any vitamins, minerals, herbs or other supplements used daily

List any allergies to medications, plants, animals or foods

Do you have or have you ever had heart disease?

Yes

If yes, please explain

To your knowledge, do you have any family history of heart disease, diabetes, stroke, or other chronic disease (in parents)?

Yes

If yes, please explain

Are you being treated for high blood pressure?

Yes

Do you have any risk factors for metabolic syndrome (large waist circumference, high triglycerides, high blood pressure, low HDL, high fasting blood sugar)?

Yes

If yes, please explain

Have you been diagnosed with any type of diabetes, pre-diabetes, insulin resistance, or do you have a high fasting blood sugar?

Yes

Do you have asthma or exercise induced asthma?

Yes

Have you ever had a seizure?

Yes

Are you or have you been anemic?

Yes

Have you been diagnosed with disordered eating or an eating disorder?

Yes

If so, please explain

Do you have or have you ever had kidney disease?

Yes

If so, please explain

Do you have or have you ever had liver disease?

Yes

If so, please explain

Do you or have you ever had stomach disease (ulcers, bleeding, etc.) or any bowel condition/disease (IBS, IBD, Crohn’s, etc.)?

Yes

If so, please explain

Do you or have you ever had frequent headaches?

Yes

If so, please explain

Do you or have you ever had a hernia?

Yes

If so, please explain

Have you ever had a concussion or head injury?

Yes

If so, please explain

Have you ever had a broken bone or fracture?

Yes

If so, please explain

Have you ever had a shoulder injury?

Yes

If so, please explain

Have you ever had a hip or knee injury?

Yes

If so, please explain

List any surgeries that you have had

Do you wear any removable dental appliances that affects your chewing or swallowing ability?

Yes

If yes, please list

Do you participate in any sports or activities? If so, which ones?

Describe the exercise you've done over the past 4 weeks

How many hours per week do you spend exercising now?

How many days per week do you take off from exercise?

Describe your longest single workout in the last 3 weeks

List each day of the week and the number of minutes/hours you can devote to exercise.

Do you currently participate in a strength training program? If so, let us know a little about it.

What is the terrain and conditions in your area? (Hilly? Flat? Windy? etc.)

Do you train with any groups? If so, let us know if you would like us to include this in your training (and the respective days and mode of training)?

Are there any specific holidays or additional commitments or priorities that you would like us to consider as we design your workout schedule?

Do you follow a specific or special diet?

List any regularly used over the counter or prescription medications

List any vitamins, minerals, herbs or other supplements used daily

Describe your sleep patterns. Do you feel that you get enough? Are you rested upon waking?

Women: Do you track your monthly cycles?

Yes

Women: If you are on any form of birth control or taking any hormone replace therapy, please list which type (or brand name) and for how long you’ve been using.

Women: Are you pregnant?

Yes

Women: If you are not post-menopausal or on a birth control method that prevents bleeding, how often do you have periods, for what duration, and how heavy is your flow?

Anything else you'd like your coach to know?

I have read and agree to the Rise Endurance Waiver.

I have read and agree to the Rise Endurance Payment & Cancellation Terms.