Let’s Tailor Your Fitness Plan

Name

Email Address

Phone

Date of Birth

Height

Weight

Physician's Name

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes No

Do you feel pain in your chest when you perform physical activity? Do you feel pain in your chest when you perform physical activity? Yes No

In the past month, have you had chest pain when you were not performing any physical activity? In the past month, have you had chest pain when you were not performing any physical activity? Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness? Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Yes No

Do you know of any other reason why you should not engage in physical activity? Do you know of any other reason why you should not engage in physical activity? Yes No

What is your current occupation?

Does your occupation require extended periods of sitting? Does your occupation require extended periods of sitting? Yes No

Does your occupation require extended periods of repetitive movements? (If yes, please explain.)

Does your occupation require you to wear shoes with a heel (dress shoes)? Does your occupation require you to wear shoes with a heel (dress shoes)? Yes No

Does your occupation cause you anxiety (mental stress)? Does your occupation cause you anxiety (mental stress)? Yes No

Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.)

Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.)

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.)

Have you ever had any surgeries? (If yes, please explain.)

Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.)

Are you currently taking any medication? (If yes, please list.)