Name (required)

Age (required)

Street

City, ST, ZIP

Email

Occupation

What are your typical work hours?

Activity Level
—Please choose an option—Sedentary (little or no exercise, desk job)Lightly active (light exercise/sports 1-3 days/week)Moderately active (moderate exercise/sports 6-7 days)Very active (hard exercise every day)Extra active (hard exercise 2 or more times per day)

Do you smoke?
—Please choose an option—YesNo

I would describe my stress levels as:
—Please choose an option—nonelowmoderatehigh


Training

Have you ever worked with a trainer before?
—Please choose an option—YesNo

Have you ever followed a formal exercise plan before (i.e. classes, personalized programs, DVDs, …)?
—Please choose an option—YesNo

Tell me a little about your training history:



Sleep

Do you sleep through the night?
—Please choose an option—YesNo

On average, how many hours of sleep do you get per night?

Do you wake up feeling rested/energized?
—Please choose an option—YesNo

Do you struggle with energy all day?
—Please choose an option—YesNo


Medical

Do you have a family history of your father or other male first-degree relative suffering a MI or sudden death before age 55?
—Please choose an option—YesNo

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by your doctor?
—Please choose an option—YesNo

In the past month, have you had chest pain when you were not doing physical activity?
—Please choose an option—YesNo

Do you feel pain in your chest when you do physical activity?
—Please choose an option—YesNo

Is your doctor currently prescribing drugs for a blood pressure or heart condition?
—Please choose an option—YesNo

Do you lose your balance because of dizziness or do you ever lose consciousness?
—Please choose an option—YesNo

Do you have a bone or joint problem that could be made worse by a change in your physical activity?
—Please choose an option—YesNo

Are you taking any other medications?
—Please choose an option—YesNo

Any other injuries/concerns we should know about? (Nothing is too small)

Do you know of any other reason why you should not do physical activity?

If my health should change so that I could answer yes to any of the above questions, I am responsible for informing my health/fitness professional.


Done