(You will be asked to sign this form & agreement on your first visit to us)
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
In the past month, have you had chest pain when you were not doing physical activity?
Do you feel pain in your chest when you do physical activity?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Do you ever lose your balance because of dizziness or do you ever lose consciousness?
Do you know of any other reason why you should not do physical activity?
Does your physician know you are participating in this exercise program?
Do you now, or have you had in the past: History of heart problems, chest pain or stroke
High or low blood pressure
Any chronic illness or condition
Difficulty with physical exercise
Advice from physician not to exercise
Recent surgery (last 12 months)
Pregnancy (now or within last 3 months)
History of breathing or lung problems
Muscle, joint or back disorder
Previous injuries not fully healed
Diabetes or thyroid conditions
Obesity (more than 20% over ideal body weight)
History of heart problems in immediate family
HIV (human immunodeficiency virus)
Hernia, or any condition that my be aggravated by lifting weights
In the past year, please tick how often have you been engaged in physical activity?
Do you feel you eat healthy “most of the time”
Please select your age range:
Select your exercise level on a scale of 1 to 5 (5 indicating very high)
Characterize your present athletic ability:
When you exercise, how important is competition?
Characterize your present flexibility capacity:
Characterize your present aerobic capacity:
Characterize your present muscular capacity:
Rate your perception of the exertion of your exercise program:
What type of exercise interest you? Please select:
Would an exercise program interfere with your job?
Would an exercise program benefit your job?
Can you exercise during your workday?
Please Rank the importance of your goals below: Improve cardiovascular fitness 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Body-fat weight loss 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Reshape or tone my body 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Improve performance for specific sport 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Improve moods and ability to cope with stress 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Improve flexibility 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Increase strength 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Increase stamina and energy level 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Feel better 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Enjoyment 1 (very important) 2 3 4 5 6 7 8 9 10 (not important) Other 1 (very important) 2 3 4 5 6 7 8 9 10 (not important)
How would you rate the amount of physical activity you perform while at work?
How physically fit do you feel at the present time?
How would you rate the amount of physical activity you perform during your leisure time?
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