Client Intake Form Template for Fitness for Diabetes Management

Use in FirstRep form

Personal Information

Gathering personal details helps tailor the fitness program to individual needs.

Aa Full Name *

Enter your full name

# Age *

Enter your age

Aa Email Address *

Enter your email

Medical History

Understanding your medical history is crucial for safe exercise planning.

v Type of Diabetes *

... Current Medications

List your current medications

# Recent A1C Level *

Enter your most recent A1C level

Exercise Experience

Assessing previous exercise experience helps to set realistic goals.

... Current Exercise Routine

Describe your current exercise routine

v Exercise Frequency *

vv Preferred Types of Exercise *

Blood Sugar Management

Understanding how you manage blood sugar during exercise is essential.

Aa Typical Blood Sugar Levels *

Describe your typical blood sugar levels

Y/N Experience with Hypoglycemia *

... Blood Sugar Monitoring Schedule

When do you check your blood sugar?

Goals and Concerns

Identifying your goals and concerns helps create a focused program.

... Primary Fitness Goals *

What are your fitness goals?

... Concerns about Exercise *

What concerns do you have about exercising?

Support System

Understanding your support system can enhance accountability and motivation.

Aa Healthcare Provider Contact *

Enter your healthcare provider's name

Y/N Family Support *

Aa Exercise Buddy

Do you have an exercise buddy?

Why Use This Template

Individualized Fitness Plans

Helps create personalized exercise plans based on your medical history and fitness goals.

Improved Safety

Identifies risks and necessary precautions before starting an exercise program.

How to Use

Fill out each section of the form carefully to ensure accurate information.

Submit the form to receive a tailored fitness plan.

Customization Tips

Add specific instructions based on your local health guidelines.
Include links to additional resources for diabetes management.
Customize the form layout to accommodate your branding.

Build and send fitness for diabetes management templates digitally with FirstRep. Free for up to 3 clients.

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Frequently Asked Questions

What should I do if I experience low blood sugar during exercise?

If you experience low blood sugar, stop exercising immediately and consume a fast-acting carbohydrate.

How can I safely incorporate exercise into my routine?

Start slowly, monitor your blood sugar, and consult your healthcare provider for personalized advice.