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ALL INFORMATION IS STRICTLY CONFIDENTIAL

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Coach Lil reviews each health evaluation personally before reaching out to schedule a free 20-minute discovery call.

Watch Coach Lil's short video below, then fill out the evaluation. It takes about 10 minutes.

Coach Lil explains what to expect

Health & Fitness Evaluation

All information is strictly confidential

1

Personal Information

Full Name *

Date *

Address *

State *

Post Code *

Email Address *

Date of Birth *

Age *

Height *

Weight *

Occupation *

Hours per Week *

EMERGENCY CONTACT

Contact Name *

Phone *

Relationship *

2

Past / Present Health History

Do you have high blood pressure? *

Yes No

Do you have high cholesterol? *

Yes No

Medications for high blood pressure or cholesterol (if applicable)

Indicate any medications above that have exercise restrictions

Family history of heart disease? *

Yes No

Do you smoke? *

Yes No

Did you quit smoking within the last 6 months?

Yes No

Do you have a pulmonary disease? *

Yes No

COPD Asthma Chronic Bronchitis

Do you have, or have you had, any other illnesses or diseases? *

Yes No

If yes, list illness / disease and treatment:

Illness / Disease	Past Treatment	Current Treatment

3

Injuries, Pain & Surgeries

Do you have, or have you had, any injuries? *

Yes No

Injuries	Past Treatment	Current Treatment

Are you currently or recently experiencing any pain? *

Yes No

Pain Location	Past Treatment	Current Treatment

Have you had any surgeries not listed above? *

Yes No

Surgery	Year	Details

Any other medical conditions that may affect your ability to exercise?

Are you pregnant or planning to become pregnant? *

Yes No

Please provide details / due date:

4

Medications

What other medications (not previously mentioned) do you take?

Medication	Exercise Restrictions	Details / Dosage

5

Current Physical Condition

Over the last 3 years, have you regularly done at least 30 minutes of physical activity, 3 days per week? *

No Yes, Moderate intensity (brisk walking) Yes, Vigorous intensity (jogging)

What physical activities do you currently do? *

Activity (gym / yoga / walk / garden, etc.)	Times Weekly	Time Spent

Past exercise history, what other types have you done? (e.g. sports) *

Have you trained with weights / resistance training? *

Yes No

Please provide details, duration and type of training:

Have you trained with a personal trainer before? *

Yes No

Please provide details, how long and type of training:

Do you follow any specific eating program? *

Yes No

Please provide details:

6

Goals & Personal Training

What are your personal health and fitness goals? *
What would you like to achieve in 6 months? In a year?

8

Declaration & Signature

Signature *

Sign with your mouse or finger

Date *

Coach Lil will review your evaluation and reach out to confirm your discovery call time. You will receive a copy of your results by email.

Thank you, evaluation received.

Coach Lil will be in touch shortly to confirm your discovery call time.
A copy of your results has been sent to your email.