Fitness and Body Image Health Questionnaire

Name (first, last): _________________________________________________________________________

Date: ___/___/___

Sex:     M     F    (circle one)

Phone# (___)______________ Work (___)____________ Current Age: _______________

Address: _________________________________________________________________________________________________

Physician's Name: ___________________________________________________________________________________________

Physician's Phone# (_____)______________________

Person to Contact in Case of Emergency Name: _____________________________________________________________________

Relationship ______________ Phone# ________________________

Are you taking any medications or drugs? If so, what? _______________________________________________________ ____________________________________________________________________________________________

If needed, does your physician know you are participating in this exercise program? ____________________________________
____________________________________________________________________________________________

Describe your exercise program now. ________________________________________________________________________ _______________________________________________________________________

Describe your basic daily food consumption and frequency for a typical day: Morning, Noon, Night, Snacks (try to be specific. pop, candy, steak, chicken) ____________________________________________________________________________________________ ____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

 

Do you now, or have you had in the past 5 years: Circle 

1. History of heart problems, chest pain or stroke.  Yes or No
2. Increased blood pressure.   Yes or No
3. Any chronic illness or condition.   Yes or No
4. Difficulty with physical exercise.    Yes or No
5. Advice from physician not to exercise.     Yes or No
6. Recent surgery (last 12 months).   Yes or No
7. Pregnancy (now or within last 3 months).  Yes or No
8. History of breathing or lung problems. Yes or No
9. Muscle, joint, or back disorder, or any previous injury still             affecting you. Yes or No
10. Diabetes or thyroid condition.  Yes or No
11. Cigarette smoking habit. 
(If so, # packs per/ day)		   Yes or No  
 _____ #_____
12. Obesity (more than 20% over ideal body weight). Yes or No
13. Increased blood cholesterol. Yes or No
14. History of heart problems in immediate family.  Yes or No
15. Hernia, or any condition that may be aggravated by lifting weights.  Yes or No
16. Rapid or runaway heartbeat.  Yes or No
17. Skipped heartbeat.  Yes or No
18. Rheumatic fever.  Yes or No
19. Has your doctor ever said your blood pressure was too high?  Yes or No
20. Shortness of breath w/ or w/out exercise   Yes or No
21. Phlebitis or embolism.  Yes or No
22. Stroke.  Yes or No
23. Do you frequently have pains in your heart and chest?  Yes or No
24. Has your physician ever said you have heart trouble?  Yes or No
25. Do you often feel faint or have spells of severe dizziness? Yes or No
26. Are you over age 65 and not accustomed to vigorous exercise?  Yes or No
27. Are you unaccustomed to vigorous exercise?  Yes or No
28. Has your doctor ever told you that you have a bone or joint
problem that has been or could be made worse by exercise?		 Yes or No
29. Recent hospitalization for any cause. List Specifics: _______________________________________________________ Yes or No
 30. Orthopedic problems (including arthritis). List specifics: _______________________________________________________ Yes or No

 

Please explain any yes answers or comments:
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

What types of exercise interest you?

Walking _____    Jogging _____       Swimming  _____    Cycling  _____    Dance Exercise  ______

Strength Training  _____    Stationary Biking  ______    Racquetball  ______    Tennis  _____    

Other Aerobic  ______________________________________________

What are your personal fitness goals? ___________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Present Height (feet/inches) ______ Weight (in pounds)  ______ Target Weight ______

Please Check::

Muscle Toning ______ Weight Loss ______

Strength Training ______ Sports Conditioning ______

Training For Running ______ Injury Rehabilitation ______

Body Building ______ Other ______

In consideration of my participation in a Nutrition, Fitness & Weight Training, Post-Rehab, Home Weight Equipment, Training Elderly, Weight Loss, Weight Gain Programs, Weight Loss Program and all Future Fitness Training Programs Offered by Darin (Owner) and Fitness and Body Image. I do hereby agree to hold free from any and all past and future liability, Fitness and Body Image, Darin (owner), his/their heirs, anyone he may represent, for myself, my heirs, executors and administrations, waive release, waive any option to sue, forever discharge any and all rights and claims for damages which I may have or which may hereafter accrue to me arising out of or connected with my participation in the Fitness and Weight Training Program. I agree that all training packages payments are non-refundable unless the trainer is not able to make it. 

Date ___/___/___ Signature ___________________________________

Date ___/___/___ Witness Signature ____________________________( If required)