| GENERAL INFORMATION: | |
| Full Name: | |
| E-mail: | |
| Date: | |
| Home Phone: | |
| Cell Phone: | |
| Business Phone: | |
GOALS:
In your own words or with the examples stated below, please list your top three goals, e.g.:
Look Better (Lower Body Fat, Muscle Definition or Mass, Girth Changes)
Feel Better (Education, Energy, Decrease Pain, Feeling of Health)
Perform Better (Cardiovascular Conditioning, Flexibility, Muscular Strength and/or Endurance, Sport-specific Results, Improve Medical Problems) |
| 1. | |
| 2. | |
| 3. | |
PERSONAL DATA: |
| Personal MD: | |
| Phone: | |
| Address: | |
| Specialist: | |
| Resting Heart Rate: | |
| Desired Body Fat: | |
| Date of Last Physical: | |
| Age: | |
| Weight: | |
| Height: | |
CARDIOVASCULAR HISTORY: |
| Have you ever had any form of heart disease? | YesNo |
| Have you ever experienced shortness of breath or chest pains? | YesNo |
RISK ASSESSMENT:
Do you have, or do any of the following pertain? (Please explain to the best of your ability) |
| High Blood Pressure: | YesNo Level: |
| High Cholesterol: | YesNo Level: |
| Cigarette Smoking: | YesNo Level: |
| Smoked in the Past: | YesNo Level: |
| Diabetes: | YesNo Level: |
| Family History of Heart Disease: | YesNo Level: |
| Abnormal Resting EKG: | YesNo Level: |
| Active: | YesNo Level: |
| Mode of Exercise / Frequency / Duration / Intensity: | |
ORTHOPEDIC HISTORY: | |
| Knee: | YesNo Level: |
| Lower Back: | YesNo Level: |
| Neck / Shoulder: | YesNo Level: |
| Hip / Pelvis: | YesNo Level: |
| Flexibility: | YesNo Level: |
| Other: | YesNo Level: |
| Are you currently taking any medications? | YesNo Level: |
| Has your doctor cleared you to engage in physical activity? | YesNo Level: |
Should my medical condition hereafter change in any way, I agree to supplement the above information as soon as reasonably possible after the date that the new information becomes known to me. |
I hereby certify that the above information is true and correct to the best of my knowledge, information and belief.
|
| Name: |
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