Minister of Fitness | Fitness Profile
Personal Fitness Profile
Club/Gym:
Name (First and Last):
Home Address:
E-Mail Address:
Home Phone:
Mobile Phone:
Date of Birth:
Sex:
Male
Female
Height:
Weight:
In Case of Emergency Contact:
Contact's Phone:
1. What is your level of physical activity?
You currently exercise
You have exercised in the past
You are currently a health club member
You have previously been a member of a health club
You have participated in a personal training program
2. What are your short and long term goals for exercise, heath and fitness?
3. Do you have any allergies? If yes, please list here, along with medications taken for them.
4. WERE YOU EVER DIAGNOSED WITH OR SUFFERED FROM:
Heart attack/heart disease?
Coronary bypas
s?
Other cardiac sugery?
Pacemaker
?
Embolism?
Stroke?
Aneurysm
?
Angina pectoris?
If you checked any of the above conditions, you must have medical clearance before exercising.
5. Check any of the following conditions that you have ever been diagnosed with:
Peripheral vascular disease
Thyroid problems
Phlebitis
Chronic bronchitis
Emphysema
Diabetes
Asthma
6. Check any of the following conditions that you frequently experience:
Chest pain
Ankle swelling
Heart murmur
Palpitations
Dizziness
Shortness of breath
Breathlessness
awakens you at night
Lightheadedness or fainting
Claudification
lower body blood clots
7. Check if any of the following applies:
High blood pressure
greater than 160/90
High cholesterol
greater than 240
Smoke cigarettes
(please give details)
Family history of coronary/atherosclerotic diseases
in parents or siblings prior to age 55
8. Are you currently pregnant?
Yes
No
9. Are you presently on a special diet?
Yes
No
10. Do you have any physical condition, impairment, or disability that might affect your ability to undertake an exercise program?
Yes
No
Additional information regarding your level of fitness or your fitness needs:
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