Assessment Form
Please type your name and today's date
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Mailing Address
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Phone Number
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E-mail
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Date of Birth (mm/dd/yyyy)
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Height (x' x'')
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Current Weight (pounds)
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Have you ever had...? (Check all that apply)
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High blood pressure
Any heart trouble
Disease of the arteries
Varicose veins
Lung disease
Asthma
Hepatitis
Diabetes Type I
Diabetes Type II
Heart Murmur
Arthritis
Kidney disease
HIV/AIDS
Hemophiliac
Seizures/Epilepsy
Blood disorders
Pacemaker
Stroke
High cholesterol
Cancer
Anemia
Thyroid Disorders
Osteoporosis
Migraines
None of the above
If there is a need to expand on of the above information, please email your trainer directly...
Have any immediate family or grandparents had...?
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High blood pressure
Any heart trouble
Disease of the arteries
Varicose veins
Lung disease
Asthma
Hepatitis
Diabetes Type I
Diabetes Type II
Heart Murmur
Arthritis
Kidney disease
HIV/AIDS
Hemophiliac
Seizures/Epilepsy
Blood Disorders
Pacemaker
Stroke
High cholesterol
Cancer
Anemia
Thyroid Disorders
Osteoporosis
Migraines
None of the above
If there is a need to expand on of the above information, please email your trainer directly...
Please list any surgeries/hospitalizations (Include type, location, and date)
Please list all current medications/supplements (Include name and dosage)
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Please list any orthopedic limitations (injuries- both past and present, areas of discomfort, etc...)
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Do you currently smoke?
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Yes
No
If yes, how often? How many packs per day?
Have you ever smoked regularly in the past?
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Yes
No
If so, how long ago did you quit, and how often did you smoke? How many packs per day?
Do you drink alcoholic beverages?
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Yes
No
If yes, how often? How much do you consume?
Do you drink caffeinated beverages?
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Yes
No
If yes, how often? How much do you consume?
Are you currently following a diet?
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Yes
No
Please explain in as much detail as possible.
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What is your current activity level?
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Sedentary (no regular physical activity)
Light (less than 30 minutes of physical activity most days of the week)
Moderate (30-60 minutes of physical activity most days of the week)
Vigorous (more than 60 minutes of physical activity most days of the week)
Please describe all current regularly performed physical activity.
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Why do you want to take part in our programs?
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Lose weight
Doctor's recommendation
Health
Enjoyment
Release of tension
Improve physical appearance
Performance
How many days a week are you HONESTLY commiting to your workouts?
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1
2
3
4
5
6
7
Where are you planning on working out?
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Home
Fitness Facility
Both
If working out at home, please describe all of the equipment that you have access to (including weight of free weights)- please be very specific.
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Goals (please describe your goals- both long term and short term, in as much detail as possible). Please include deadlines if they exist.
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How did you hear about us?
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From a friend/family member
Facebook
Twitter
Other
If other, please explain
I hereby state that all of the information presented in this form is complete and true to the best of my knowledge. I accept that by taking part in this exercise program I am doing so at my own risk.
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I accept
I do not accept. I understand that by doing so, I will be unable to participate.
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