Name

Email Address

Address

City

State
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Zip Code

Home Phone

Cell Phone

Fax #

Business Phone

Physician's Name

Physician's Phone Number & Fax

Date of Birth

Age

Sex
Choose From Below Male Female

Height

Weight

Weight 1 year ago

Weight at 21 years of age

 

1. Has your doctor ever said you have heart trouble or any cardiovascular problems?

yes
no

2. Do you frequently suffer from pains in your chest?

yes
no

3. Have you ever suffered from a heart attack?

yes
no

4. Do you experience an irregular or racing heart rate during exercise or at rest?

yes
no

5. Do you often feel faint or have spells of severe dizziness?

yes
no

6. Has a doctor ever said that your blood pressure is too high?

yes
no

7. Do you often have difficulty breathing?

yes
no

8. Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?

yes
no

9. Are you over age 65 and not accustomed to vigorous exercise?

yes
no

10. Are you diabetic?

yes
no

11. Are you pregnant?

yes
no

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If you answered YES to any of the above questions, written physician approval is required prior to beginning an exercise program.

12. Date of last complete physical examination:

Results (Normal):

Results (Abnormal):

13. List any medications you are now taking and the reason for which they were prescribed:

14. List any operations you have had (include date):

17. Has any member of your immediate family been diagnosed with Heart Disease, Diabetes, Hypertension, Stroke, Obesity or High Cholesterol? Indicate who and age at time of diagnosis.

19. Indicate any of the following, which currently exist or have existed in the past:

Anemia, Artery Disease, Arthritis, Asthma, Back Pain/Injury, Bleeding Trait, Bursitis, Cancer, Diabetes, Dizziness, Epilepsy, Headaches, Gout, Heart Murmur, Heart problem, HIV/AIDS, Hernia, High Blood Pressure, Hypoglycemia, Joint Problem, Kidney Problem, Liver Disease, Lung Disease, Phlebitis, Pregnancy, Rheumatic Fever, Serious Injury, Shortness of Breath, Stroke, Ulcer, Varicose Veins, Weight Problems

21. If you are not satisfied, what changes would you make?

22. How much water do you drink per day?

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LIFESTYLE

23. Occupation

24. Number of hours worked per week at your job:

25. How do you spend most of your time at work?

sitting at desk
walking
driving
standing
carrying loads
other:

26. Do you smoke? yes   no
Do you smoke cigarettes? yes  no
Do you smoke cigars? yes   no
Do you smoke pipes? yes   no
How many per day?
Did you ever smoke? yes  no
when did you quit:

27. Indicate how you are coping with daily stress on a scale of 1-10:

28. Indicate your energy level on a scale of 1-10:

29. On the average, how often do you get 7-8 hours of sleep?

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HEALTH RELATED BEHAVIOR

30. How many times per week do you engage in moderate or strenuous exercise for at least 20 minutes?

Describe.

How long have you been doing this?

31. Have you ever begun an exercise program and then stopped?

yes
no

When?

Why did you stop?

32. How many times per week do you plan to exercise over the next year?

For how long?

At what intensity?

What times of day are best for you?

What days are best for you?

33. What would you like to achieve through participation in a fitness program?

34. In order to match you with the trainer who has the personality and the right experience to help you achieve your goals, please indicate what you are looking for in a personal trainer?

35. What is your favorite activity?

How often do you do it?

36. List any other factors which might affect your safe participation in a fitness assessment or fitness program:

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I heard about Mind, Body & Soul from:

Name of Website, if applicable: