Health History & Fitness Behavior Questionnaire Name: Address: Phone: %mail: %mergen$y )onta$t: Todays Date: Age:

hm! Pre&eren$e to 'e $onta$ted( *elationshi+:

Gender: M F "#! Phone:

$ell!

Please circle (or underline or bold if electronic) the answer that best applies below. Part , - Health History 1. Do you have any of the following diseases? a. Peripheral arterial disease (PAD) b. Cerebrovas ular disease (in luding stro!e) . Chroni "bstru tive Pul#onary disease (e#physe#a$ hroni bron hitis) d. %ung disease e. &hyroid disorder f. 'enal disease g. %iver disease (. a. a. .. 0. a. 1. a. 2. Do you have diabetes? a. )f yes* please ir le if it is insulin dependent diabetes #ellitus ()DD+) or non,insulin dependent diabetes #ellitus (N)DD+). b. )f yes* how #any years have you had diabetes? /as your do tor ever said you have heart trouble? Do you have asth#a? a. )f yes* do you ta!e asth#a #edi ation? Are you* or do you have reason to believe* you #ay be pregnant? b. )f yes* when is your due date? )s there any other physi al reason that inhibits you fro# parti ipating in an e3er ise progra#* (e.g.* an er* osteoporosis* severe arthritis* #ental illness* autoi##une disorder* et .)? Please list4 -------------------------------------------------5. -----------------------------------------------------------------------No No No No No No No No )DD+ Yes Yes Yes Yes Yes Yes Yes Yes N)DD+

-------- years No No No No Yes Yes Yes Yes

------- due date No Yes

%ist the #edi ations you ta!e on a regular basis and des ribe their purpose.

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Part . - /igns and /ym+toms 6. 7. Do you ever have pain or dis o#fort in your hest or surrounding areas* espe ially during e3er ise? Do you ever feel faint or di88y (other than when sitting up rapidly)? No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes

19. Do you find it diffi ult to breathe when you are lying down or sleeping? 11. Do your an!les ever be o#e swollen (other than after a long period of standing)? 1(. Do you ever have heart palpitations or an unusual period of rapid heart rate? 1.. Do you ever e3perien e painful burning or ra#ping in the #us les of your legs (i.e. inter#ittent laudi ation)? 10. /as your physi ian ever said that you have a heart #ur#ur? a. )f yes* has s$he said it is safe for you to e3er ise? 11. Do you feel unusually fatigued or find it diffi ult to breathe with usual a tivities? Part 0 - )ardia$ *is# Fa$tors 12. Are you a #an 01 years of age or older* or a wo#an 11 years of age or older? 15. /as your father* #other* brother* or sister had a heart atta !* heart surgery* or sudden death before the age of 11 (#ale) or 21 (fe#ale)? 16. Do you s#o!e igarettes on a daily basis* or have you :uit s#o!ing re ently (within the past 2 #onths)? a. )f yes* about how #any igarettes do you s#o!e per day? 17. Do you parti ipate in a regular e3er ise progra#* or a u#ulate .9 #inutes or #ore of #oderate physi al a tivity at least 1 days per wee!? (9. /as your do tor ever told you that you have high blood pressure? a. )f yes* are you on any antihypertensive #edi ation? (1. Please indi ate the following values if !nown4 a. ;lood Pressure b. &otal seru# holesterol . /D% holesterol d. %D% holesterol e. &rigly erides f. <asting ;lood =lu ose level g. Please indi ate when you had these values #easured? ((. Please indi ate the following infor#ation as a urately as possible. Your personal trainer is available to #easure these values. a. b. a. /eight------- in b. >eight------- lbs . >aist ir u#feren e d. 'esting /eart 'ate

No No No

Yes Yes Yes

-------- igs$day Yes No No No Yes Yes

---- $ --- ##/g -------- #g$dl -------- #g$dl -------- #g$dl -------- #g$dl -------- #g$dl ------ $----#o $ yr

------- in or # -------- bp#

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Part 1 - %2er$ise 3ntentions & )urrent %2er$ise Behavior (.. Do you want to e3er ise at a #oderate intensity (e.g.* bris! wal!ing) or at a vigorous intensity (e.g.* ?ogging)? (0. >hat is your o upation? ----------------a. /ow physi al is your wor!? +ostly sitting %ight wor! +oderate wor! Yes @igorous No (1. Do you urrently engage in regular aero'i$4$ardio a tivities su h as fitness wal!ing* ?ogging* swi##ing* ardio e:uip#ent* aerobi s lasses or videos* et ? )f yes4 a. Ape ify type(s) of a tivities? b. <re:uen y4 --------- e3er ise sessions per wee! . Cir le$bold )ntensity4 %ight +oderate @igorous d. Duration4 ---------- #inutes per session e. /ow long have you been doing ardio regularly( (2. Do you urrently parti ipate in resistan$e training on a regular basis? a. )f yes* des ribe your urrent resistan e training routine (in lude fre:uen y* duration* sets and reps* et .)4 (5. Do you urrently pra ti e regular &le2i'ility training? a. )f yes* des ribe what you do and how often4 Part 567ther Health 3ssues (6. Do you have any bone or ?oint proble#s that need to be onsidered in developing an appropriate wor!out plan? %ist any in?uries whi h $urrently bother you (e.g.* sprains* #us le pulls* bursitis* tendonitis* bro!en bones* et .). Please note the spe ifi lo ation of these in?uries. Yes No Yes No +od, erate @igorous

(7. Do you have any other #edi al ondition or physi al reason not #entioned earlier that #ight need spe ial attention in an e3er ise progra# (e.g.* arthritis* fibro#yalgia* he#ophilia* sei8ures* eating disorder* et .). )f yes* please des ribe below.

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Part 86Pre&eren$es and 3nterests *elated to Health & Fitness .9. >hat is your #ain #otivation in see!ing professional assistan e? .1. >hat are your spe ifi fitness goals ()ndi ate all that apply)? --- Bstablish B3er ise habit --- )#prove ardiovas ular fitness --- )n rease strength and enduran e --- )#prove fle3ibility --- &rain for a triathlon ---Aports onditioning4 ---)n?ury 'ehabilitation ---)#prove #us le tone ---)n rease #us le #ass ---&rain for Cy le "regon* A&P* et .

--- &rain for running event* i.e. 1!* 19!* #arathon --- "ther4 --------------------------------------------------------.(. >hat are your spe ifi health goals (indi ate all that apply)? --- )#prove energy level --- )#prove nutrition --- <eel better overall --- A hieve balan e in #y life --- 'edu e body fat --- Control holesterol --- Control blood pressure --- Atop s#o!ing --- 'edu e stress --- Prevent or ontrol diabetes

"ther4 ------------------------------------------------------------... Are you interested in losing weight or #aintaining your urrent weight? )f you are interested in weight loss* please answer the following :uestions4 a. >hat do you thin! is a realisti e3pe tation for weight loss? b. Are you interested in having your body o#position assessed (i.e.* height* weight* ir u#feren es* s!infold #easures)? .0. >hat type(s) of aerobi a tivities do you prefer ( he ! all that apply)? --- >al!ing outdoors --- Bllipti al or Cross,trainer --- 'owing #a hine --- Cy ling outdoors --- B3er ise videos --- <ree weights --- >eight #a hines --- ;ody weight --- Cogging outdoors --- Atair stepper --- 'e u#bent bi!e --- >ater e3er ise --- =roup <itness lasses --- Du#bbells --- ;owfle3 --- B3er ise videos --- &read#ill --- Atep +ill --- Apinning bi!e --- %ap Awi# --- "ther4---------- Dynabands --- Atability ball --- Pilates Yes No

------ lb$w! Yes No

.1. >hat type of resistan e training do you prefer ( he ! all that apply)?

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.2. Do you urrently parti ipate in any re reational or o#petitive sports? --- =olf --- ;owling --- Cy ling --- Ao er --- @olleyball --- 'a :uet sports --- ;as!etball --- Awi##ing --- "ther4 --------

Yes

No

.5. Do you prefer to wor!out alone* with a partner* or in a group? ---------------.6. Are there a tivities that you do not li!e and would li!e to avoid? .7. >hat barriers have you e3perien ed in the past that have !ept you fro# e3er ising regularly? B3plain. 09. >ould you li!e to do the sa#e a tivities regularly (i.e. routine)* or would you prefer variety in your wor!out s hedule? 01. )n the hart below* please indi ate the ti#e of day and length of ti#e you plan to wor!out on any given day. Mon Tue 9ed Thu Fri )ndi ate ti#e of day you will wor!out )ndi ate length of ti#e you have available.

/at

/un

) have read* understood* and o#pleted this :uestionnaire and attest that it is truthful and o#plete to the best of #y !nowledge. ) understand that this infor#ation will be !ept onfidential. ) also understand that a physi al e3a# #ay be ne essary prior to beginning a health and fitness progra#. ) agree to provide any do u#entation fro# #y health provider indi ating that it is safe for #e to parti ipate in an e3er ise progra# and provide any li#itations that s$he feels #ay be ne essary. Aignature4 /TAFF :/% 7N;< Health /$reening Data: 'esting /'4 ----------&arget /eart 'ate4 *is# /trati&i$ation $ir$le!: /igned Forms re$eived: --- Cleared to e3er ise --- Ataff signature4 ;lood Pressure ------$-----29D /''---------+oderate 'is! --- 'elease <or# 'eason4 Date4 Date4 %ow 'is! --- )nfor#ed onsent --- Needs #edi al learan e ;+)4 -----------61D /'' ------------Client$&rainer Agree#ent /igh 'is! 09D /'' --------Date4

--- 'e eived #edi al learan e (atta h)

This &orm is in $om+lian$e "ith: ACSMs Guidelines for Exercise Testin and Prescription !th Edition ((996). %ippin ott* >illia#s* E >il!ins Publisher.

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