GENERAL INFORMATION

First Name:
Last Name:
Date of Birth:
Social Security #:

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Home Phone:
Work Phone:
Mobile Phone:
Email Address:
Occupation:
Employer:

Employer Address: ,    ------AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY       +

Have you completed a physical in the past year?:    -- Choose -- Yes No

Month:
Year:
Family Physician:
Physician Phone:

In case of emergency, please contact:

Contact Phone #:
Relationship to you:

Do you work out now?:    -- Choose -- Yes No

If yes, at the Gym or Home?:    -- Choose -- Gym Home

Do you consider yourself:    -- Choose -- Sedentary (little, if any, vigorous activity) Lightly Active (sporadic workout, little aerobic, lawn work) Moderately Active (workout 1-2 days/wk for 15-30 min.)option> Highly Active (workout 3+ days/wk for 30-45 min.)

Check all that apply:        Over the age of 16     Exercise at least 10 hours/week - consistently for at least 6 months     Have a resting heart rate of 60 beats per minute or less     Have been very fit for years, but currently exercise less than 10 hours/week

What activities do you prefer in an exercise program?:

What is the most you have ever weighed?:

Do you frequently participate in competitive sports?:    -- Choose -- Yes No

If yes, what sports?:

What high school or college athletics did you participate in?:

Do you smoke?:    -- Choose -- Yes No

Have you ever smoked?:    -- Choose -- Yes No

How many?:

When did you quit?:

HOSPITALIZATION

Have you ever been hospitalized with any illness or injury?:    -- Choose -- Yes No

If yes, please explain (include year and reason):

ORTHOPEDIC

Have you ever had any bone, joint, muscular, back injuries, or conditions?:    -- Choose -- Yes No

If yes, please explain:

FAMILY HISTORY

Do any of your immediate family members (grandparents, parents or siblings) have, or have had,
any of the following?

		Name	Age
Heart Disease?:	-- Choose -- Yes No
Heart Attack?:	-- Choose -- Yes No
Heart Surgery?:	-- Choose -- Yes No
Blood Pressure?:	-- Choose -- Yes No
Stroke?:	-- Choose -- Yes No
Diabetes?:	-- Choose -- Yes No
Vericose Veins?:	-- Choose -- Yes No
High Cholesterol?:	-- Choose -- Yes No
Sudden Death?:	-- Choose -- Yes No

Other:

CURRENT MEDICATIONS

Name of Medication	Dose	How Often	Reason

Are you allergic to any medications?:    -- Choose -- Yes No

If so, which one(s):

PERSONAL HISTORY

Heart Disease:	-- Choose -- Yes No	Heart Attack:	-- Choose -- Yes No
Heart Surgery:	-- Choose -- Yes No	Disease of the Artery:	-- Choose -- Yes No
Angioplasty:	-- Choose -- Yes No	Heart Murmur:	-- Choose -- Yes No
Rheumatic Fever:	-- Choose -- Yes No	Stroke:	-- Choose -- Yes No
Anemia:	-- Choose -- Yes No	Phlebitis/Emboli:	-- Choose -- Yes No
Emphysema:	-- Choose -- Yes No	Asthma:	-- Choose -- Yes No
High Cholesterol:	-- Choose -- Yes No	Chronic Bronchitis:	-- Choose -- Yes No
Chest Pain/Discomfort at rest:	-- Choose -- Yes No	Chest Pain w/ exertion:	-- Choose -- Yes No
Shortness of Breath:	-- Choose -- Yes No	Swelling of the feet/ankles:	-- Choose -- Yes No
Skipped or rapid heart beats:	-- Choose -- Yes No	Kidney Disease:	-- Choose -- Yes No
Epilepsy:	-- Choose -- Yes No	Liver Disease:	-- Choose -- Yes No
Arthritis/Swollen, stiff joints:	-- Choose -- Yes No	Dizzy Spells:	-- Choose -- Yes No
Diabetes:	-- Choose -- Yes No	Emotional Disorders:	-- Choose -- Yes No

Recent Illness:

-- Choose -- Yes No

Please explain:

If female, are you pregnant?:

-- Choose -- Yes No

If yes, how far along?:    Months

HIGH BLOOD PRESSURE

Have you ever been told you have high blood pressure?:    -- Choose -- Yes No

If yes, what was the treatment you received?:

Are you still being treated for high blood pressure?:    -- Choose -- Yes No

FITNESS GOALS

What are your fitness goals?: