[one_third] Today’s date: [/one_third]

[one_third] Name: [/one_third]

[one_third_last] Age: [/one_third_last]

[one_third] Address: [/one_third]

[one_third] Town: [/one_third]

[one_third_last] State: [/one_third_last]

[one_third] Zip: [/one_third]

[one_third] Phone Number(s): [/one_third]

[one_third_last] Email: [/one_third_last]

[one_half] Gender: MaleFemale [/one_half]

[one_half_last] If female- any chance you are pregnant? NoYes [/one_half_last]

[one_half] Any history of spinal injury or injury to a joint or muscle? [/one_half]

[one_half_last] Does it still affect you? Please describe: [/one_half_last]

The following section will be completed by the trainer at the initial consultation:

[one_half] Current Bodyweight(lbs.): [/one_half]

[one_half_last] Current Body Fat Percentage(%): [/one_half_last]

Body Girths:

[one_half] Waist(inches) [/one_half]

[one_half_last] Hips(inches) [/one_half_last]

Legs

[one_half]Left(inches)[/one_half][one_half_last]Right(inches)[/one_half_last]

Upper Arm

Forearms

[one_half]Shoulders(inches) [/one_half]

[one_half_last]Chest(men only)(inches) [/one_half_last]

[one_half] What are your current health/fitness goals? [/one_half]

[one_half_last] What are the main reasons for your goals? [/one_half_last]

Check any symptoms of possible coronary or metabolic disease you have recently experienced:

Chest painshortness of breathdizzy/faintingankle swellingheart palpitationsleg/feet crampingheart murmur

Risk factors for CHD (Coronary Heart Disease), MI (heart attack), Stroke or hypertension (usually caused by atherosclerosis):

[one_fourth] Do you smoke? NoYes [/one_fourth]

[three_fourths_last] [one_half]How much? [/one_half] [one_half_last]perDayWeekMonth[/one_half_last] [/three_fourths_last]

[one_third] Did you quit smoking less than 6 months ago? NoYes [/one_third]

[one_third] Do you take antihypertensive medications? NoYes [/one_third]

[one_third_last] Are you currently taking Beta-blockers? NoYes [/one_third_last]

[one_third] Do you get at least 30 minutes of moderate physical activity everyday? NoYes [/one_third]

[one_third] Do you have osteoporosis? NoYes [/one_third]

[one_third_last] Do you have osteoarthritis? NoYes [/one_third_last]

[one_third] Do you suffer from back pain? Yes(upper)Yes(mid)Yes(low)No [/one_third]

[one_third] If yes, how often? RarelyDailyWeeklyMonthly [/one_third]

[one_third_last] Are you often stressed? NoYes [/one_third_last]

[one_half] If yes, how does it physically manifest? HeadacheStomachSleeplessIrritableOther [/one_half]

[one_half_last] How many times do you get sick (common cold) per year? 1234More [/one_half_last]

[one_half] Do you have diabetes? NoYes(type I)Yes(type II) [/one_half]

[one_half_last] Are you taking any medications? List: [/one_half_last]

[one_third] Do you eat low, moderate or high carbs? LowMidHigh [/one_third]

[one_third] Do you eat low, moderate or high protein? LowMidHigh [/one_third]

[one_third_last] Do you eat low, moderate or high fat? LowMidHigh [/one_third_last]

[one_half] Do you eat a variety of foods (whole grains, dairy, lean meats, fruit & vegetables with limited fat/oils)? YesNo [/one_half]

[one_half_last] How many calories do you eat per day?(Kcal) [/one_half_last]

[one_third] What level of importance do you place on exercise? NoneLowAverageModerateEssential [/one_third]

[one_third] How often do you currently exercise? [/one_third]

[one_third_last] What type(s) of exercise do you usually perform? [/one_third_last]

[one_half] How many days per week do you want to commit to exercise? 1234567 [/one_half]

[one_half_last] How many minutes per day? 20 or lessabout 304560an hour (+) [/one_half_last]

Rate your fitness (1-Poor, 5-Average, 10-Excellent):

Cardio-Respiratory 12345678910

Strength 12345678910

Endurance 12345678910

Flexibility 12345678910

Power 12345678910

Body Composition 12345678910

Self-Image 12345678910

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