In order to accurately design a program to suit your needs, we ask that you complete the following health/medical questionairre. This information is strictly confidential.

Personal Information
Name:
Gender: Male       Female
Age:
DOB: mm-dd-yyyy
Height:
Weight:
Address:
City:
State:
Zip:
Day Phone:
Eve Phone:
Fax:
Email:
Emergency Contact Information
Name:
Relation:
Phone:
Name of personal Physician:
Date and reason last consulted:
Medical History
Have you had or do you have:
Heart Attack
Angina
Abonormal Electrocardiogram
Heart Medications
Valve Disease
Aneurysm		 Thrombophlebitis
Asthma
Fixed Rate Pacemaker
Embolism
Respiratory Infections
Irregular Heart Beats		 Rapid Heart Beats
High Blood Pressure
Low Blood Pressure
Diabetes
Epilepsy
Anemia
Has your physician advised you against exercise? Yes     No
If YES, why and when?
Do you have any of the following conditions?
Arthritis
Low Back Pain
Calcium Deposits
Head/Neck Injury
Hip/Pelvis Injury		 Ankle/Foot Injury
Arm/Elbow Injury
Nerve Damage
Bone Fracture
Tennis Elbow		 Shoulder Clavicle Injury
Knee/Thigh Injury
Upper Back Injury
Wrist/Hand Injury
If you checked any of the items above please explain.
Are you currently receiving physical therapy? Yes     No
If YES, what is your therapist's name:
What is your therapist's phone number?
May we call him/her? Yes     No
Do you smoke? Yes     No
If YES, how often:
For how long:
Do you have any past injuries that limit the range of motion of your muscles, joints, bones, spinal column, or any other part of your body which may be aggravated by exercise? Yes     No
If YES, explain.
Are you taking any medications on a regular basis? Yes     No
If YES, list names and dosage.
Are you currently under a doctor's care? Yes     No
If YES, name and phone number of doctor.
What is your current weight?  
What was it one year ago?  
Five years ago?  
At age twenty? 
Are you currently on a specific diet? Yes     No
If YES, please describe.
Are you tired of fatigued most of the day? Yes     No
Are you tired or fatigued at a specific time of day? Yes     No
If YES, when?
On the average, how many hours per day do you spend at work?  
How many days per week?
How would you rate the amount of physical activity you perform while at work?
Very Little      Little      Moderate      Active      Very Active
How would you rate the amount of physical activity you perform during leisure time?
Very Little      Little      Moderate      Active      Very Active
Are you presently performing any physical fitness program? Yes     No
If YES, please explain in detail.
How physically fit do you feel presently?
Unfit      Below Average      Average      Above Average      Very Fit
Do you have exercise equipment devices at home? Yes     No
Do you participate in highschool or college athletics? Yes     No
If YES, describe.
Do you feel there are any activities which would not interest you or cause you pain or discomfort? Yes     No
If YES, please specify.
Briefly describe your exercise history.
What are your primary reasons for consulting with Personal Fitness?
General Conditiong Weight Loss Muscular Strength
Stress Reduction Flexibility Cardiovascular Conditioning
Other, Please specify
Other concerns and comments.
 
How did you hear about PFP?
 
Signatures
LEAVE THESE FIELDS BLANK, YOU WILL SIGN THIS FORM WHEN YOU COME IN FOR YOUR APPOINTMENT.
Client Signature: ______________________________________________
PFP Rep Signature: ____________________________________________