Please provide the following information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail

Date of Birth
Sex	Male Female
Height
Weight

What is your Resting Pulse:

Does your doctor know you are participating in this exercise program?

Yes No

Do you currently participate in exercise regularly?

Yes No

If yes, please describe your exercise. Include number of days per week and the amount of time you exercise.

Do you currently smoke?

Yes No

If yes, how many years have you smoked and how many cigarettes do you smoke per day?

Do you have high blood pressure?

Yes No

Last Blood Pressure Reading:

Do you take any Blood Pressure Medications:

Do you have high cholesterol?

Yes No

Last Cholesterol Reading:

Cholesterol Medication:

Do you have a family history of heart disease prior to age 55?

Yes No

If yes, please specify:

Do you experience any of the following? (Mark all that apply)

chest pain             fainting               dizziness              ankle swelling       
leg pain               shortness of breath    heart murmur           loss of consciousness
irregular heartbeat    

Please answer the following questions regarding your personal health.

Do you or have you had heart disease?

Yes No

If yes, please specify:

Have you had a stroke:

Yes No

If yes, when:

Do you have asthma:

Yes No

Do you have epilepsy:

Yes No

Do you or have you had any back injuries:

Yes No

If yes, please specify:

Do you have any orthopedic problems:

Yes No

If yes, please specify:

Do you have arthritis/bursitis:

Yes No

If yes, please specify:

Do you have any muscular weakness or injuries:

Yes No

If yes, please specify:

Do you have any allergies:

Yes No

If yes, please specify (include food, medicines, etc):

Have you ever had an abnormal EKG?

Yes No

Date of most recent EKG:

Any major illnesses or hospitalizations within the last six (6) months?

Yes No

If yes, please specify:

Have you had a medical examination in the past year?

Yes No

Date:

Do you have any other concerns?

Yes No

If yes, please specify:

What are your fitness goals?

Please describe your diet- List the time and portion for each meal/snack that you have during the day. Please include all snacks, sides, and beverages.

Please provide an Emergency Contact Name:

Emergency Contact Phone Number: