Name (Full): Date:
Address: Age: Date of Birth:
City: State: Zip:
Home Phone: Business Phone:
Cellular Phone: Email:
Sex: Male Female
Height:
Weight:
In Case of Emergency contact: Phone:
Name of Physician: Address of Physician:
Date and reason last consulted:
Has your physician ever advised you against exercising? Yes No
If yes, please explain:
1. After reviewing your questionnaire, it may be necessary for me to obtain medical clearance from your physician before beginning and exercise program with you. If it is necessary to contact your physician regarding your health status, may I have your permission? Yes No
2. Do you now or have you ever experienced any of the following:
3. Do you have or did a physician ever diagnose you as having any of the following:
Condition(s) not listed:
4. Are you presently under a physician's care for any of the above, or for any other condition? Yes No
May I call him/her regarding your condition and treatment? Yes No
5. Have you had any major illnesses and/or surgeries? Yes No
If Yes, please explain:
6. Do you have any current medical problems or incompletely healed injuries? Yes No
7. Have you had or do you now have any bone, joint (including spine), or muscle injuries and or diseases? Yes No
8. Are you presently receiving physical therapy? Yes No
If Yes, please explain for what condition:
Please provide your therapists name, address, and phone number:
9. At present, do you have any pain in any part of your body? Yes No
If Yes, please explain (if No, go to question #13)
10. Is there any position, activity, exercise or task that causes you concern or pain? (for example, heavy lifting, prolonged sitting, etc,)
Yes No
11. In what way(s) do your symptoms interfere with your daily activities?
12. If you are experiencing any pain or discomfort, what causes the symptoms?
13. Do you experience any tingling, numbness, or feelings of weakness in ant part of your body? Yes No
14. Do you experience any problems with your posture or with movement? Yes No
Do you feel this is a result of: Pain Stress/Tension Previous Injury Habit Patterns
15. Are you presently taking any medications? Yes No
If Yes, please list the names and reasons for taking and the dosage for each:
16. Have you ever had a graded exercise "stress" test? Yes No
If Yes, When: Reason for test: Result:
17. Do you smoke? Yes No If Yes, how many packs a day:
for how many years?
18. if you do not smoke now, have you ever smoked in the past? Yes No
If Yes, how many packs a day: for how many years?
When did you quit?
19. Do you have a family history of heart disease (heart attack, stroke, unexplained death) Yes No
If Yes, who and what age at onset (only list immediate family - mother, father, siblings):
20. Do you have a family history of high blood pressure? Yes No
If YES, who:
Age at on set:
Type of treatment:
21. Do you have a family history of diabetes? Yes No
If Yes, who:
22. Do you experience stress? Yes No
If Yes, when do you experience it (for example at home or work):
On a scale from I- 10 (with 10 being very high), How would you rate your stress level? --Select One-- 01 - 02 -- 03 --- 04 ---- 05 ----- 06 ------ 07 ------- 08 -------- 09 --------- 10 ----------
23. Do you drink alcohol? Yes No
If Yes, how often do you drink (times per week)?
Type of alcohol consumed:
How much do you consume?
24. Do you drink coffee, tea, soft drinks or other types of beverages containing caffeine? Yes No
If Yes, what type of beverage, how much, and how often:
25. Describe your current diet (for example what you typically eat for breakfast, lunch and dinner):
26. Do you have any children? Yes No If Yes how many:
27. Rate your general health: Excellent Good-Fair Poor
28. Rate you general level of fitness: Excellent Good-Fair Poor
29. What type of work do you do? (occupation):
30. Rate the amount of physical activity you perform while at work:
Very Little Little-Moderate Active Very Active
31. List the physical demands of your job:
32. Do you exercise? Yes No
If Yes, is it Regular Infrequent
Describe your routine (for example, type of activity, duration, frequency, intensity):
33. If not currently exercising, have you in the past? Yes No
If Yes, was it Regular Infrequent
Describe your past routine (for example type of activity, duration, frequency, intensity):
34. What type of exercise activities do you like best?
What type of exercise activities do you like the least?
35. Do you have any exercise equipment at home? Yes No
If Yes, what kind:
36. Approximately how much time per week can you devote to your exercise program:
37. What are your personal fitness goals? (please check)
38. Additional comments or pertinent information:
Full Name:
Date Accepted:
I Agree
