Client Intake Form Template for Cardiac & Heart Health Fitness

Use in FirstRep form

Personal Information

Collects essential data about the client to tailor cardiac fitness programs.

Aa Name *

Enter your full name

# Age *

Enter your age

v Gender *

Aa Emergency Contact *

Enter emergency contact name and number

Medical History

Understanding clients' medical history helps in designing safe exercise programs.

vv Heart Conditions *

Y/N Hypertension *

... Current Medications

List any medications and dosages

Current Fitness Level

Assessing fitness levels ensures appropriate exercise intensity and progression.

v Exercise Frequency *

... Current Activity Levels

Describe your current exercise routine

1-10 Intensity Comfort Level *

Goals and Motivations

Identifying specific goals helps in creating focused fitness plans.

v Primary Fitness Goal *

... Motivation for Exercise *

What motivates you to exercise?

Exercise Barriers

Understanding barriers helps in addressing challenges faced during workouts.

1-10 Anxiety About Exertion *

... Physical Limitations

List any physical limitations or concerns

... Medication Side Effects

Describe any side effects impacting exercise

Monitoring and Coordination

Coordination with healthcare providers ensures safe exercise practices.

Aa Cardiologist Name

Enter your cardiologist's name

D Last Checkup Date *

... Blood Pressure Readings

Recent blood pressure readings

Why Use This Template

Safety First

Ensuring all clients exercise safely according to their health conditions.

Personalization

A tailored approach improves client adherence and outcomes.

How to Use

Distribute this form to new clients during their first appointment.

Review the completed form to address any concerns before starting the program.

Customization Tips

Add questions specific to previous cardiac events.
Include a section for preferred exercise types.
Tailor the intensity scale to your client's comfort level.

Build and send cardiac & heart health fitness templates digitally with FirstRep. Free for up to 3 clients.

Start for Free See All Features

Frequently Asked Questions

How can I be sure this program is safe for me?

This program is designed based on your medical history and current health status, ensuring safety in all activities.

What should I do if I experience discomfort during exercise?

Stop exercising immediately and consult your healthcare provider for guidance.