Please provide the following information

Please provide the following contact information:

Fitness Level:     Beginner     Intermediate    Advanced

Please list any recreational activities or hobbies you are involved in:

1. Has a doctor ever said that you have a heart condition and that you should only perform activities recommended by a doctor? YES NO
2. Do you feel pain in your chest when you perform physical activity? YES NO
3. Do you lose your balance because of dizziness or do you lose consciousness? YES NO
4. Do you have a bone or joint problem that could be made worse by a change in your physical activity? YES NO
5. I your doctor currently prescribing any medication for your blood pressure or for a heart condition? YES NO
6. Do you know of any other reason why you should not engage in physical activity? YES NO
7. Have you ever had any pain or injuries (ankle, knee, back, shoulder, etc.) YES NO If yes please explain
8. Have you ever had any surgery? YES NO If yes please explain
9. 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? YES NO If yes please explain
10. Are you currently taking any medication? YES NO If yes please explain
11. Do you have any allergies? YES NO If yes please explain

What are your short term goals?

What are your long term goals?

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